Health Screening Consent / Contact Form

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

Employee Health Screening Consent / Contact Form

Public reporting of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Informed Consent

Before you get started, we’d like need to give you some more information to help you decide whether or not you would like to participate.

• This project is funded by the Centers for Disease Control and Prevention. Many parts of the project are being managed by Viridian Health Management (Viridian). Viridian is a private health and wellness company based in Phoenix, AZ. Viridian provides customized solutions to building comprehensive healthy worksite programs. They are helping CDC implement the National Healthy Worksite (NHW) program.

• You were asked to participate because your worksite is participating in the National Healthy Worksite (NHW) program as a benefit to employees. All employees at your worksite will be asked to complete this health screening consent/contact form at the beginning and at the end of the NHW program.

• Your participation in this health screening is voluntary. You may choose not to participate or end the health screening at any time.

• Completing the health screening consent/contact form is designed to take about 10 minutes.

• All of the information you provide will be maintained in a secure manner. We will not disclose your information or anything about you unless we are compelled by law. Your information will be combined with other information we receive and reported in the aggregate as feedback from the group. In our project reports, your name will not be linked to the comments you provide in this discussion.

• CDC is authorized to collect information for this project under the Public Health Services Act.

• There are no personal risks or personal benefits to you for participating in this discussion.

• We are interested in your comments so that we can improve the NHW program for future participants. Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER]. [HIS/HER] number is [INSERT TEL #]. You can also call Viridian Health Management toll-free at 1-877-486-0140.

Instructions

To make sure that health-related information and programs are tailored to affect your health problems and concerns, we are asking each employee to voluntarily fill out this consent/contact form.

If you have any questions, Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER]. [HIS/HER] number is [INSERT TEL #].

_{Participant Information:}

_{Company Name:}

_Location:

Last Name First Name Middle/2nd Name

Participant’s Date of Birth (mm/dd/yyyy)

Best Phone Number to Reach You: Alternate Phone Number (home, work, cell)

-

Email Address

FOR OFFICE USE ONLY - Do not complete below this line

Participant / Member ID

REQUIRED CLINICAL INFORMATION TO BE COMPLETE BY CLINICAL STAFF AT ONSITE SCREENING EVENT
Height	FEET INCHES	Fasting Status	Fasting ___ Non-Fasting___ Unknown ___
Weight	LBS	Total Cholesterol	mg/dL
Waist Measurement	INCHES	HDL	mg/dL
Pulse Rate	BPM	Triglycerides	mg/dL
Blood Pressure	/ (SYSTOLIC /DIASTOLIC)	LDL Cholesterol	mg/dL
Body Mass Index (BMI)		TC / HDL Ratio
		Glucose	mg/dL

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Technician Name Date Time Referred to MD 

Employee Informed Consent

Biometric Screening and Health Assessment

You are being asked to voluntarily participate in a program called the National Healthy Worksite (NHW) Program. This project is funded by the Centers for Disease Control and Prevention (CDC), a federal government agency that is funding this project because research has shown that workplace wellness programs can positively affect employee health. The goal of this program is to learn more about the effects of workplace health promotion policies and practices on the health and well-being of employees. About 23,000 employees from multiple employers across the country will participate in this project. The number of employees participating may vary at each work site.

Who is providing the worksite health program?

Viridian Health Management is implementing the workplace programs and collecting data, in collaboration with the University of Connecticut Health Center. Research Triangle Institute International, a non-profit research organization, is conducting a national evaluation of the NHW program.

Why am I eligible to participate?

Your employer has agreed to be a part of the NHW program. Your participation is important to this project because no one else in the organization is exactly like you. However, your participation in any and all program offerings is strictly voluntary.

What do I have to do to be part of this project?

Participation in the study is completely voluntary and you can stop at any time. The National Healthy Worksite program has 3 parts. For Part I of the program, we ask you to take part in health screening that includes some biometric screening tests and questions about your health and health habits.

For the biometric screening, we will:

• Take your blood pressure and pulse using a manual blood pressure method (blood pressure cuff, stethoscope, and sphygmomanometer)

• If you are able to stand unassisted, measure your height while you are standing

• If you are able to stand unassisted, ask you to stand on a scale to measure your weight

• Use a finger prick to obtain a small blood sample to obtain a lipid profile and blood glucose

• If you are able to stand unassisted, measure your waist circumference with a flexible tape measure

The biometric screening and health assessment will take approximately 30 minutes.

Will you tell me the results of my biometric screening?

At the end of the biometric screening, you will receive all of your testing results with an explanation of each result. After completing the health assessment, you will receive a personal report which explains your results. You will have the opportunity to discuss your results with a health coach.

How are privacy and confidentiality maintained?

The National Healthy Worksite program is strongly committed to respecting your privacy and the confidentiality of the information you provide us. Your name will be replaced with a number for the purposes of evaluating program results. Your information is completely confidential and will not be shared with your employer. Information will be combined with data from other participants in the program and only group results will be reported. Your individual data will also be shared with Viridian Health Management onsite health coaches to provide individual health coaching interventions specific to your current health status and lifestyle habits.

What are the benefits of participating in the National Healthy Worksite program?

You may benefit from learning more about your health. You will receive a card with your blood pressure and BMI results and information on what they may mean. You can show the results to your doctor for follow-up questions. This is an opportunity for you to make a valuable contribution to your workplace. The results of this program will describe the health and well-being of employees and their families, and will also provide valuable information about your workplace .

What are the potential risks involved in participating?

The risks related to participating in the basic health measures and health assessment are minimal. It is possible that some of the questions in the health assessment may make you feel slightly uncomfortable, but you can skip any questions you don’t want to answer. You may also learn that you are at risk for a future health condition, which you may prefer not to know. The possible risks associated with taking a blood sample by fingerprick include but are not limited to, the risk of infection, discomfort, and bruising.

How can I learn more about the National Healthy Worksite Program?

If you have any questions about this program, please call 1-877-486-0141. You can also e-mail us at [email protected].

I

CDD National Healthy Worksite Program Consent Form

voluntarily consent to participate in National Healthy Worksite Program, a worksite wellness program which is being conducted by Viridian Health Management. I understand that this program includes health screenings, health assessments, and individual and group health coaching and education. The health screenings and health assessments include biometric screening tests. I understand that a blood sample is to be withdrawn by fingerstick and I have been made aware of the possible risks associated with this, including but not limited to, the risk of infection, discomfort, and bruising. I understand that the explanations that I receive may not be all-inclusive and that other, more remote risks may be involved. However, the information that I have received is sufficient for me to consent and authorize the collection of the blood specimen.

I understand and consent to additional biometric screening tests by Viridian Health Management listed on the reverse side of this form.

I understand that Viridian Health Management will have access to my health screening results and other health status and lifestyle behaviors obtained through the health assessment. These results may be used to refer you to a healthcare professional, contact you for follow up, and health coaching. I understand that my individual results are private, and will not be shared with my employer. Group (summary) statistics may be used for reporting including your employer. No other individual or entity will have access to my individual test results without my authorization or as allowed by law.

Viridian Health Management will provide the health assessment results to me at the time of my health screening. The health assessment results that I receive are for informational purposes only and are NOT a medical diagnosis. It is my sole responsibility for initiating any follow up examination with my doctor to discuss any questions, to have the meaning of any test explained, to review and interpret my health assessment results and to obtain medical advice. Viridian Health Management has no such responsibilities.

I have received a copy of the Health Insurance Portability and Accessibility Act (HIPAA) Notice of Privacy Practices and Employee Informed Consent. I know I can get additional information from Viridian Health Management by calling 1.877.486.0141.

I release Viridian Health Management from any and all liability arising from the collection of my biometric screening tests and the reporting of information concerning such analysis by Viridian Health Management consistent with the activities outline in this consent form.

I, the participant named below, have read, understood, and agree to the terms of this National Healthy Worksite consent form. No attempts by the participant to modify or amend this form will change its terms in any way be binding upon Viridian Health Management.

X Participant’s Signature: __________________________ Date: ____________

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