Pilot Employer Application Form

[

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

CDC Work@Health Pilot Training Employer Application Form

Public reporting of this collection of information is estimated to average 5 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 many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current 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).

This is an online form for employers and organizations who support employer workplace health program efforts who are interested in participating in the pilot test of the Work@Health training program. This form will be available in summer – fall 2013 to enroll organizations.

Introduction

Organizations interested in participating in the Work@Health pilot are encouraged to complete the form on the Work@Health website or submit a completed form to [email protected].

Informed Consent

We’d like 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 (CDC). Many parts of this project are being managed by the ASHLIN Management Group (ASHLIN). ASHLIN is a private business consulting firm concentrating in the area of health and human services based in Greenbelt, MD. They are helping CDC implement the Work@Health program. The Public Health Management Corporation (PHMC), a non-profit, public health institute located in Philadelphia, PA is conducting this survey.

• You are being asked to share your contact information so that we can communicate with you about the Work@Health pilot training.

• Your participation is voluntary, and you may skip any questions you do not want to answer. You may also choose to stop filling out the form at any time.

• This form is designed to take about 5 minutes.

• There are no right or wrong answers or ideas – we want to hear about YOUR experiences and opinions.

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

• There are no risks or benefits to you personally for completing this form.

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

• If you have any questions, you can contact Kristin Minot. Her phone number is 215-985-2519 and her email is [email protected].

Eligibility Requirements

The CDC Work@Health training program is open public and private employers and organizations who support employer workplace health program efforts.

Employers interested in the hands-on, online, or blended training models meet the following requirements:

1. The organization is located in the one of the following training site locations:

TBD

2. The employer has a minimum of 30 full time employees.

3. The employer offers health insurance to all eligible employees and covers all or part of the following medical services after the deductible / co-pay is met:

a. Preventive care (preventive office visits, preventive lab and x-ray, pap smear and mammography, flu and pneumonia immunizations, endoscopic services including but not limited to colonoscopy).

b. Physician Services (office visits, diagnostic lab and x-ray, allergy testing, injections [including allergy], inpatient and outpatient services, surgery, emergency room visits).

c. Mental Health, chemical and alcohol dependency (inpatient services, outpatient and office therapy sessions).

4. The employer had a valid business license.

5. The employer has been in business for at least one year.

6. The employer is committed to fully participate in the pilot training session.

Employers and organizations that support employer workplace health program efforts interested in participating in the train-the-trainer model meet the following requirements:

1. The organization is located in the one of the following training site locations:

TBD

2. A referral from one of the following types of organizations

   1. State or local Health Department

   2. Employer membership organization

   3. Community-based health organization

   4. Private/non-profit organization

3. Workplace health program knowledge and skills as evidenced by:

   1. Completion of the Work@Health Program Online, Blended OR Hands-on training model OR

   2. Knowledge and skills that are substantively equivalent to those expected in the Work@Health curriculum as demonstrated within a workplace health/wellness program or on-the-job and documented in a portfolio assessment.

4. Training skills and experience including:

   1. At least one year of successful experience instructing, coaching or facilitating employers/employees in workplace health/wellness knowledge and skills;

   2. Intermediate proficiency and comfort using technology in online and blended training models.

5. Implementing workplace health programs

a. At least one year of successful experience in a leadership role implementing a workplace health/wellness program in a business, agency or organization.

6. The organization is committed to fully participate in the pilot training session.

Contact Information

First Name _____________________________________________

Last Name _____________________________________________

Title __________________________________________________

Company/Place of Business _______________________________

Street Address _________________________________________

City _________________________________________________

State _________________________________________________

Zip code ______________________________________________

Phone number _________________________________________

Email address __________________________________________

Company website _______________________________________

Employee Characteristics

1. Number of employees at your site or business unit

• Less than 30

• 30 – 100

• 101- 500

• 500 – 1000

• 1001 or more

2. Does your organization have a workplace health program (i.e., a coordinated and comprehensive set of health promotion and protection strategies implemented at the workplace that includes programs, policies, benefits, environmental supports, and links to the surrounding community designed to encourage the health and safety of all employees)?

• Yes

• No [If no, skip to question 5]

1. How many years has your company’s workplace health program been in existence?

   • Two years or less

   • Three years

   • Four years or more

2. Which of the following elements of workplace health programs are currently offered at your organization: (check all that apply)

 Health education (e.g., skills development and behavior change classes; awareness building brochures, posters)

 Links to related employee services (e.g., referral to employee assistance programs (EAPs)

 Supportive physical and social environment for health improvement (e.g., tobacco free policies, subsidized gym memberships)

 Integration of health promotion into your organization’s culture (e.g., health promotion being part of business’ mission statement)

 Employee screenings with adequate treatment and follow up (e.g., Health Risk Assessments (HRAs) and biometric screenings)

5. With respect to addressing employee health issues at your workplace, how ready is your company to take action?

   • Not at all ready (not seriously thinking about making a change, unaware that employee health is/may be an issue)

   • Not quite ready (thinking about employee health issues, weighing the pros and cons of taking action, but not ready to take action)

   • Somewhat ready (committed to taking action but researching options/gathering information on what to do)

   • Almost ready (active preparation and planning after settling on what actions will be taken)

   • Completely ready (all preparations and planning are complete, moving into action)

6. What industry best describes your worksite?

• Agriculture, Forestry, Fishing and Hunting

• Mining, Quarrying, and Oil and Gas Extraction

• Utilities

• Construction

• Manufacturing

• Wholesale Trade

• Retail Trade

• Transportation and Warehousing

• Information

• Finance and Insurance

• Real Estate and Rental and Leasing

• Professional, Scientific, and Technical Services

• Management of Companies and Enterprises

• Administrative and Support and Waste Management and Remediation Services

• Educational Services

• Health Care and Social Assistance

• Arts, Entertainment, and Recreation

• Accommodation and Food Services

• Public Administration

• Other Services (specify) _________________________

The following section is to be completed by organizations interested in being in the train-the-train pilot test.

In the box below, please describe your previous workplace health training experience or preparation (including formal coursework, certifications, credentials, etc).

In the box below, please describe your experience in developing or implementing workplace health programs (what was your role, what programs/services were provided to employees, length of experience, how was the program evaluated, etc).

Please send you referral form to [email protected]

Optional: If you would like to receive more information about the CDC Work@Health Program, or if you would like to participate in the Program training, please visit the following link:: www.cdc.gov/workathealth

7