Workplace Wellness Grant Program

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness
Grant Program
Overview and Forms

Governor John R. Kasich
Administrator/CEO Stephen Buehrer

Workplace Wellness Grant Program

1

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness
Grant Program

Purpose of program ............................................................................................................................3
How to apply .......................................................................................................................................3
Program requirements ........................................................................................................................5
Employer responsibilities ....................................................................................................................6
Required program data .......................................................................................................................8
Workplace Wellness Grant Program Application .................................................................................10
Safety Management Self-Assessment................................................................................................13
Workplace Wellness Grant Program Contract .....................................................................................16
Requirements for annual case study ...................................................................................................21

Workplace Wellness Grant Program

2

Attachment E2 OHBWC WWGP Overview and Forms

Purpose of program
To meet the challenges of obesity, rising incidence of chronic diseases,
and the aging workforce, BWC has established the Workplace Wellness
Grant Program to assist employers with the creation and implementation
of a workplace wellness program. Scientific research has shown that the
aforementioned challenges contribute to increased incidence and cost of
workplace accidents and illnesses. The program’s goal is to limit and control
the escalating cost of workers’ compensation claims by helping employers
develop health promotion programs for their employees. The secondary
goals are to reduce health-care costs for employers, as well as improve the
health and well-being of the workforce.
Employers who receive the grant will be required to share aggregated
data related to their employees’ health risk factors and costs with BWC,
demonstrate proper use of grant awards, and effective implementation of
the wellness program in their workplaces. BWC will subsequently use the
data to determine the effectiveness of the wellness program on workers’
compensation claims frequency, claims cost, and the timeliness of postinjury return to work.

How to apply
Step 1 – Contact your local BWC service office, Employer Services Division
to find a safety and health consultant who will verify your eligibility and
determine the availability of funds (1-800-OHIOBWC or ohiobwc.com).
Step 2 – Review program requirements.
Step 3 – Complete the following and mail to Ohio Bureau of Workers’
Compensation, Workplace Wellness Grant Program, 13430 Yarmouth Drive,
Pickerington, OH 43147-8310. All signatures must be original.
o Application and narrative
o Legal agreement/contract
o Safety management self-assessment
Step 4 – Below is a list of three forms required to receive grant funds from
the state. All signatures must be original. Mail all three completed forms
to Ohio Shared Services, Attn: Vendor Maintenance, P.O. Box 182880,
Columbus, OH 43218-2880. If you have questions, you may contact Ohio
Shared Services at:
Phone: 1-877-644-6771
Fax: 614-485-1039
Email: [email protected]
o Vendor form (As a grant recipient the state considers you a
vendor)
o Direct deposit form
o W-9 tax form
Step 5 – Contact safety and health consultant from step 1 who will review your
application with you in person or by phone prior to submission.
Step 6– BWC will evaluate the application and send a letter to you stating
whether you are approved or denied for the grant program.
Workplace Wellness Grant Program

3

Attachment E2 OHBWC WWGP Overview and Forms

What is a wellness program?
There are several ways to define a workplace wellness
program. According to the Harvard Business Review: A
workplace wellness program is “An organized, employersponsored program that is designed to support employees
(and, sometimes, their families) as they adopt and sustain
behaviors that reduce health risks, improve quality of
life, enhance personal effectiveness, and benefit the
organization’s bottom line.”

Elements of an effective Workplace Wellness
Program
Research has shown that effective wellness programs
use a multi-faceted approach. Utilizing the elements listed
below are proven to achieve results.

1.
2.
3.
4.

Obtain senior leadership commitment
Develop a written wellness program
Include a wellness plan in the business operations plan
Develop a wellness team or appoint a wellness
coordinator
5. Collect data through surveys and screenings
6. Identify and deliver health promotion programs
and services which will benefit your workers
based on surveys and screenings
7. Continuously evaluate and improve the program

Grant eligibility requirements
The following is a list of eligibility requirements to receive
a workplace wellness grant.
o Be a state-fund employer
o Be current on monies owed to BWC – not more
than 45 days past due
o Maintain active coverage – not more than 40 days
lapsed in the prior 12 months
o Must contract with a third party wellness program
vendor. Existing contracts will not be considered.
o Currently does not have a wellness program
 A workplace wellness program consists of:
1. The following tools - a health risk appraisal
and a biometric assessment – both of which
measure health risk factors;
2. Programs designed to address those health
risk factors.
o If an employer only has one of the above numbers
1. (tools) or 2. (programs), then they do not have an
existing wellness program and are eligible to apply
for the workplace wellness grant.
*Berry, L., Mirabito, A., Baun, W. What’s the Hard Return on Employee
Wellness Programs?: The ROI data will surprise you, and the softer
evidence will inspire you. Harvard Business Review. Dec. 2010. 104-112.

o If the employer has both 1. (tools) and 2. (programs)
listed above, we consider that an existing wellness
program and the employer is not eligible to receive
a workplace wellness grant.

Funds
Employers participating in the grant fund may receive $300
per participating employee over a four-year period, which
equates to a maximum amount of $15,000 per policy.
A “participating employee” is defined as someone who
completes a health risk appraisal and biometric screening
in the first three months of the first year and each of the
subsequent years of the grant program and participates in
at least one activity to improve or maintain his/her health in
each program year. The $300 is divided over the four years
per employee as follows
Year 1

Year 2

Year 3

Year 4

Total

$100
$75
$75
$50
$300 per

employee

Use of grant funds
Employers will be required to work with a wellness
program vendor and incorporate the essential components
of a successful wellness program, as determined by
the leading authorities in wellness and steps outlined
underneath “Elements of an effective workplace wellness
program.” Wellness grant funds must be used for health risk
appraisals (HRA), biometric screenings, and subsequent
activities designed to address the results of the screening
and assessment including, but not limited to, weight-loss
management programs, educational seminars on improving
health, physical fitness activities, and nutritional counseling
to benefit the participating employees.
Funds may not be used to cover salaries, wages, internal
labor or any costs associated with preparing the application.
In addition to the above, funds may not be used to purchase
incentive items to encourage participation in the wellness
program. Funds must be solely used to compensate the
external wellness program vendor for providing HRAs,
biometric screenings, and administering and designing a
workplace wellness program. Funds may not be used to
purchase exercise equipment.
BWC will hold a company responsible for using the grant
in the intended manner. An employer may face civil and/

Workplace Wellness Grant Program

4

Attachment E2 OHBWC WWGP Overview and Forms

or criminal sanctions if it misappropriates and/or misuses
grant funds or misrepresents information when submitting
a request for grant funds or any documents submitted for
the purpose of securing grant funds.

Professional employer organizations (PEOs)/
client relationship
State-fund employers who are in a PEO/client relationship
are eligible to apply for a workplace wellness grant. The
client employer must apply under its own BWC policy
number and will be responsible for obtai ning all claims data
from their PEO as required for participation in the wellness
grant program. This claims data includes a four-year claims
history and follow-up claims data reported yearly to BWC
for up to four years for employees participating in the
wellness program. In addition, the employer must provide
a baseline case study at the time of applying for the grant
and a yearly case study thereafter on the effectiveness of
their workplace wellness program.
o PEOs are eligible to apply for the wellness grant
under their own policy number. These grants can only
be used for operations owned or operated by the
PEO and not for any client employer.

Program requirements
Complete the application and narrative
Employers applying to receive grant funds are required to
submit a completed application and narrative. The purpose
of the narrative is to help BWC understand the goals of the
program, the steps taken in the past and the methods that
will be used to measure program effectiveness.

Complete the safety management
self-assessment survey
Each eligible applicant must complete the safety
management self-assessment when applying for the
workplace wellness program grant. The self-assessment
information will be used to identify opportunities for
assistance from BWC’s Division of Safety & Hygiene to
improve your overall workplace safety and health.

Submit the required data for employees
participating in program
Employers participating in the wellness grant program
are required to enter (1) aggregated biometric data,
(2) aggregated health risk appraisal (HRA) data, and (3)
employee information including participating employee
names for each year of program participation and claims
data. The data is due within three months of the grant
application approval, and in subsequent years within
three months after the year-end case study. You will
receive instructions for what information is required for
the employee participation data with the employer grant
approval letter from BWC.

Submit a copy of the vendor contract
Employers who are approved to receive workplace
wellness grant funds will contract with a wellness
program vendor. Employers will have three months from
the date on the approval letter to provide BWC a copy
of the contract between the employer and the wellness
program vendor.

Submit a year-end case study
Employers who receive grant funds are required to
submit a case study to BWC at the end of each year of
participation in the Workplace Wellness Grant Program
The case study will be due one year after the grant approval
date. The purpose of this case study is to assess the
safety, wellness, and claims management and to assist
with establishing best practices for the implementation
of workplace wellness programs. You must submit this
report electronically within 30 days of the anniversary
date to [email protected].

Workplace Wellness Grant Program

5

Attachment E2 OHBWC WWGP Overview and Forms

BWC access
The employer agrees to allow BWC to inspect original
program records of wellness program participants
upon demand and on-site in the event that questions
arise regarding the participation. The employer will also
cooperate with BWC by providing access to information to
help it measure the effectiveness of the wellness program.
The employer will allow BWC to publish Workplace
Wellness Grant Program results, including but not limited
to literature, data, videos, specifications, and/or photos
for the purposes of illustrating, educating, and training
employers and employees.

Grant recipient names
Pursuant to Ohio Revised Code 125.112 (F), BWC is
required to post to ohiobwc.com the names of grant
recipients and dollar amounts awarded.

Employer responsibilities
Contact BWC
The employer is required to contact their local BWC service
office to establish a working relationship with a safety and
health consultant who will help to verify their eligibility,
determine availability of funds, and provide support and
guidance for the program.

Vendor selection guidelines
BWC is providing the following wellness program vendor
guidelines to assist the applicant in the selection of a
vendor. BWC does not endorse the use of any particular
vendor. When choosing a vendor, we suggest that you
determine if they have the following knowledge, experience
and resources. Also, see conflicts of interest and ethics
compliance certification in the agreement.

BWC programs

1. Access to licensed health professionals, health

Employers participating in other BWC programs are eligible
to apply for this grant. These programs include grouprating, retrospective rating, Drug-Free Safety Program,
safety intervention grants, and the safety council discount
program.

2. Personnel with strong business backgrounds and

BWC and IRS requirements
BWC must issue an IRS 1099 form to you for all unused
and/or unverified funds. Acceptable verification is your paid
invoice and copies of cancelled check(s) to verify payment.
If you fail to submit all documentation in accordance with
the terms of the Workplace Wellness Grant Program,
and/or you have not verified how you spent the funds by
Dec. 31 of a given year, the award could be considered
income received and may be taxable. (Note: The issuance
of a 1099 form does not preclude BWC from seeking
administrative, civil and/or criminal sanctions, if you do not
reimburse the bureau all unused grant money and/or funds
deemed misappropriated.)

Program document requirements
Employers who desire to participate in the workplace
wellness grant program must submit the completed
application, narrative, and the safety management selfassessment survey to BWC.
Additionally.employers must submit the vendor information
form, direct deposit form, and a W-9 tax form to Ohio
Shared Services (see page 12)

coaches and counselors
analytical skills

3. Experience in developing wellness programs for
companies in your industry

4. Knowledge of legal and regulatory compliance
5. Secured data systems
6. Online portal and other means of collecting protected
health information data and providing guidance

7. Health risk appraisal (HRA) and biometric analysis software
8. References
Employers may also consider the following certifications
when deciding on a vendor.
NCQA = National Committee Quality Assurance
URAQ = Utilization Review Accreditation Commission
Tips:

1. Please carefully review the eligibility requirements and
ensure you qualify for the grant.

2. BWC suggests you review the required data elements

with potential vendors. This way, the vendor will know
upfront whether they will be able to assist you in meeting
the program requirements.

3. Make sure the vendor is aware that the grant will be
awarded AFTER the HRA and biometric data elements
are reported to BWC. This may assist you in setting up
a payment system between yourself and the vendor.
Workplace Wellness Grant Program

6

Attachment E2 OHBWC WWGP Overview and Forms

Change of vendor
If for any reason you need to change your wellness
program vendor, immediately notify BWC. After securing a
new vendor, please notify BWC and provide a copy of the
contract between you and new vendor.

Employer requirements for each year of
participation
Employers participating in the program may qualify to
receive funds over a four-year period. The following
requirements must be met to receive funding each year.

1) Complete all application questions (only in the first year)
2) Complete the safety management self-assessment
3) Submit the application to BWC for approval (only in
the first year)

4) Obtain approval for the grant funds.
5) Complete the following steps within three months of

receiving application approval:
oo Execute a contract with a wellness program vendor
and submit a copy to BWC.
oo Complete HRAs and biometric screenings through
your wellness program vendor
oo Submit baseline data to BWC (HRAs, biometrics,
employee data.)
6) Submit a yearly case study
7) Submit paid, itemized invoices and copies of all cancelled
checks to support all invoices associated with the workplace
wellness grant within 3 months of reporting the data
elements, employee data, and narrative or case study.

Limitations
o An employer is also strictly prohibited from improperly
obtaining access to or disclosing personal health information.
o Employers are also prohibited from coercing
employees into participating in wellness programs.
An employer will be removed from the grant program and
may face civil and criminal sanctions accordingly, if BWC
finds any of these to be true.

Disqualification
If for any reason the employer participating in the program
fails to satisfy one or more of the criteria established in
the application and instructions, Ohio Administrative Code
(OAC) 4123-17-56.1, and the following agreement, including
but not limited to the requirement of maintaining active
coverage, timely payments therefore, and the obligations
described in the Employer responsibilities and requirement
for each year of participation sections, BWC may disqualify
the employer from the program. Disqualification will result

in termination of BWC’s obligations under this agreement,
and BWC reserves the right to recover grant monies by one
or more of the following methods: billing the employer for
the grant money received, forwarding to the Office of the
Attorney General of Ohio for collection, set-off, recoupment,
or other civil and/or legal remedy.
If the employer merges or combines its business after receiving
a grant but before completing the year-end case study reporting,
the BWC Successorship Liability Policy will go into effect.
The grant/predecessor employer is responsible for
notifying the successor employer of the obligations under
the Workplace Wellness Grant Program.
The successor employer may be liable to repay any and all
previously paid grant monies if these obligations are not met.

Grant review process
When BWC receives the completed application, it will review
the applicant’s eligibility, and ensure that all questions have
been addressed and all forms are completed. BWC will
then send the application to the Workplace Wellness Grant
Review Board for a review of the application.
The board evaluates the applications individually, approving
or denying the applications based upon their merit. If
approved, you will receive a letter explaining the next steps
in the grant award process. If denied, BWC will return the
application to you with a letter of explanation.

Signature on application and agreement
Private employers are required to sign the application and
agreement, signifying that they are either the owner, chief
executive officer, chief financial officer, plant manager or other
person having fiduciary responsibilities with the employer;
and the employer agrees the signer or his or her successor
will have the authority to oversee the carrying out of the
employer’s responsibilities for one year from the date of the
grant check. The signer’s authority will continue until the
employer notifies BWC of the name of the successor.
Public employers are required to sign the application and
agreement, signifying that they have primary fiduciary
responsibilities under the public employer’s BWC policy
number; and the employer agrees the signer or his or her
successor will have the authority to oversee the carrying
out of the employer’s responsibilities for one year from the
date of the grant check.

Workplace Wellness Grant Program

7

Attachment E2 OHBWC WWGP Overview and Forms

Required program data
This is a list of data elements BWC requires from participating employers and their wellness
vendor. BWC intends to use this data to determine the effectiveness of participation in a wellness
program.
This information must be reported to BWC within three months of receiving approval to participate
in the Workplace Wellness Grant Program.

Employee data
Listed below is the specific employee data required by BWC from an employer.
1. Total number of employees in the company
2. Total health-care utilization cost (non-workers’ comp) if available for each of the past four
years
3. Total number of hours worked by the participating employees in each of the previous four
years
4. Employee absenteeism rate for participating employees
• Year one of grant program (employer must report the last four years)
• Years two, three and four (employer must report the prior full year)
5. Workers’ compensation claims that have been filed by the participating employees
• Year one of grant program (employer must report the last four years)
• Years two, three and four (the employer must report the prior full year)
BWC suggests you review the required biometric and health risk appraisal (HRA) data with
potential vendors. This way, the vendor will know upfront whether they will be able to assist you
in meeting the program requirements.

Workplace Wellness Grant Program

8

Attachment E2 OHBWC WWGP Overview and Forms

Biometric data

Below is the specific aggregate data required by BWC from
the biometric screenings, which are services provided by
a wellness program vendor. This data must be entered
each year of participation in the workplace wellness grant
program.
1. Body mass index (BMI)
Percentage of participating employees who are
underweight, normal, overweight or obese
{{Underweight <18.5
{{Normal
18.5 – 24.9
{{Overweight
25 - 30
{{Obese
> 30
2. Blood pressure
Percentage of participating employees with low,
normal, elevated or high blood pressure
{{Low
< 90/60  
{{Normal
90-120/60-80 
{{Elevated
121-139/81-89
{{High
> 140/90 High
3. Blood glucose
Percentage of participating employees with normal,
elevated or high blood glucose levels (fasting)
{{Normal
80-100
{{Elevated
101-125
{{High
>125
4. Total cholesterol
Percentage of participating employees with desirable,
elevated or high total cholesterol
{{Desirable
< 200
{{Elevated
200-240
{{High
>240
5. LDL cholesterol
Percentage of participating employees with optimal,
good, elevated or high LDL cholesterol
{{Optimal
< 100
{{Good
100-129
{{Elevated
130-160
{{High
> 160

Health risk appraisal data
Below is the specific aggregate data required by BWC from
the health risk appraisals, which are services provided by
a wellness program vendor. This data must to be entered
each year of participation in the workplace wellness grant
program.
1. Percentage of participating employees with specific
health risk factors
{{0-2
{{3-4
{{5 or more
2. Percentage of participating employees engaged in the
following ranges of physical activity
{{Excellent
{{Good
{{Fair
{{Poor/sedentary
3. Percentage of smokers among participating
employees
4. Percentage of participating employees with the
following nutritional habits
{{Excellent
{{Good
{{Fair
{{Poor
5. Percentage of participating employees who can be
categorized in the following stress levels
{{Very high
{{High
{{Moderate
{{Low
{{Little or no stress

6. HDL cholesterol
Percentage of participating employees with optimal,
good or low HDL cholesterol
{{Low
< 40 (men) < 50 (women)
{{Good
50-60
{{Optimal
> 60
7. Triglycerides
Percentage of participating employees with normal,
elevated and high triglycerides
{{Normal
< 150
{{Elevated
150-200
{{High
> 200
Workplace Wellness Grant Program

9

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness Grant Program Application

Workplace Wellness
Grant Program Application
Employer information
Name of employer

Doing business as (DBA) name
Address
City

State

ZIP code

County

Employer industry: Check box
Manufacturing

Cities

Service (e.g., health care, day care centers, fast food restaurants, hotels)

Counties

Office w ork

Transportation

Construction

Agriculture

Commercial (e.g., retail stores, delivery services, w arehouses/distribution)

Tow nships

Unclassified

Villages

Schools

Other

BWC policy number

Federal tax ID number

Employer contact name
Title
Telephone number (w ith extension)
Fax number
Email address

Budget
You may use the w orkplace w ellness grant for items such as HRAs, biometric screenings, aw areness training,
health-coaching services and the development of a w orkplace w ellness program.
You may NOT use the w orkplace w ellness grant funds for employee incentives, recouping the cost of any prior
and/or ongoing w ellness program, or fitness/exercise equipment. In addition, you may not use w orkplace w ellness
grants to pay for salaries, w ages, internal labor or any costs associated w ith preparing the application.

BWC-6626 (Rev. 3/05/2012)

SH-27

Page |1

Workplace Wellness Grant Program

10

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness
Grant Program Application
Please provide the estimated budget for your wellness plan.

Type of service

Estimated cost

Total

By my signature, I agree to fully comply w ith the terms and conditions of the program and to use all monies solely
for the purposes intended. I further understand I may be subject to civil, criminal and/or administrative penalties as
the result of any false, fictitious and/or, misleading or fraudulent statements made and/or if funds are not used, or
are misused, misapplied, or misappropriated in any w ay and/or are used for purchases and/or services not
associated w ith the approved budget.
Name of duly authorized representative (please print)
Signature of duly aut horized representative
Title

Date

Narrative
Employer Profile
1. Provide a description of your organization and business.
2. How many employees w ork for your company?
3. Have you encountered any difficulties in the past w hen trying to implement w ellness in you r company? If yes,
w hat w ere they?
4. Have your employees completed a health risk appraisal w ithin the last 12 months? If yes, explain w ho provided
the service and how the information w as used.
5. Have your employees completed a biometric screening w ithin the last 12 months? If yes, explain w ho provided
the service and how the information w as used.
6. What w ellness program elements have been in place over the last 12 months? Identify all that apply.
Physical fitness component (e.g., w alking)
Weight -management program
Nutritional counseling
Educational sessions
Health fairs
Discounts
Incentives
Other health promotion activities

BWC-6626 (Rev. 3/05/2012)

SH-27

Page |2

Workplace Wellness Grant Program

11

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness
Grant Program Application
Proposed program
1. How many of your employees are interested in participating in a w ellness program?
2. What is (are) the name of your employee(s) responsible for implementing your w orkplace w ellness program?
What is their contact information?
3. Please explain your company’ s w ellness culture and commitment to w ellness, including:
Management level;
Departmental level.
4. Provide a timeline for the implementation of your w ellness program.

There are three documents required in order for the employer to receive grant monies from the state.
Below is a list of the three forms to fill out and attach to the application.
Vendor form (As a grant recipient the state considers you a vendor)
http://ohiosharedservices.ohio.gov/document.aspx?id=098c86b4-3755-4a72-8415-77964ad22128
http://ohiosharedservices.ohio.gov/document.aspx?id= 098c86b4 -3755-4a72-8415-77964ad22128
Direct deposit form
http://ohiosharedservices.ohio.gov/document.aspx?id=48f6b55e-d979-4949-b8da-84ef680392fc
http://ohiosharedservices.ohio.gov/document.aspx?id= 48f6b55e-d979-4949-b8da-84ef680392fc
W-9 tax form
http://www.irs.gov/pub/irs-pdf/fw9.pdf?portlet=103
http://w w w .irs.gov/pub/irs-pdf/fw 9.pdf?portlet= 103

BWC-6626 (Rev. 3/05/2012)

SH-27

Page |3

Workplace Wellness Grant Program

12

Safety Management Self-Assesment

Attachment E2 OHBWC WWGP Overview and Forms

Safety Management Self-Assessment

Company name

Policy number

Industry type (Autopopulate)

Average number of employees

This assessment is intended to help employers evaluate their safety and claims management systems and identify opportunities
for improvement. It should be completed by the person(s) in the organization who are most familiar with the current safety and
claims management process. Please read each of the statements below and select the rating that best represents your level of
agreement with that statement. The estimated time to complete this assessment is 15 minutes.
Upon completion of the assessment, please refer to the Resource Guide on the Industry-Specific Safety Program page for a list
of suggested activities and BWC Division of Safety & Hygiene resources you can utilize in the areas you wish to improve. If
you would like personal assistance completing the safety review or implementing any of the suggested activities, please call
1-800-OHIO-BWC.
Rating scale: 1 = strongly disagree,

2 = disagree,

3 = agree,

4 = strongly agree,

NS = not sure

A.

Management commitment – The level of commitment that management demonstrates to the safety and health process
1. A concise, documented policy that establishes safety and health as a core value that is equally important as production,
service and quality has been communicated to all employees by top management.
n 1 n 2 n 3 n 4 n NS
2. Management allocates adequate time and resources to support the organization’s safety and health efforts.
n 1 n 2 n 3 n 4 n NS
3. Top management establishes safety and health program goals, and regularly evaluates and communicates the
organization’s safety performance.
n 1 n 2 n 3 n 4 n NS

B.

Accountability – The process that is used to assign safety and health management responsibilities and to evaluate, recognize
and reward performance
1. Safety and health responsibilities are assigned to the appropriate personnel and are specifically addressed in the performance review of each employee.
n 1 n 2 n 3 n 4 n NS
2. Individuals with assigned safety and health responsibilities are provided with the skills, knowledge, resources and
authority to perform their duties effectively.
n 1 n 2 n 3 n 4 n NS
3. Supervisors conduct regularly scheduled safety inspections, safety briefings, observations, coaching and other assigned
activities.
n 1 n 2 n 3 n 4 n NS

C.

Employee participation –The extent to which the employees participate in and are encouraged to be involved in the safety
and health of the workplace
1. Opportunities are provided for employees to participate in the safety process through activities such as safety committee
meetings, safety team projects and safety awareness event planning.
n 1 n 2 n 3 n 4 n NS
2. Employees are involved in safety goal setting, strategy development and safety process improvements.
n 1 n 2 n 3 n 4 n NS
3. Employees actively participate in safety and health training by identifying needed training topics, assisting with
development and delivery of training, and assisting with on-the-job training and mentoring of new employees.
n 1 n 2 n 3 n 4 n NS

D.

Safety culture – The organizational values, management style, environment and social norms related to safety and health
1. The organization fosters trust and open communication on occupational safety and health issues by encouraging
discussion and feedback on all issues that are raised.
n 1 n 2 n 3 n 4 n NS
2. Collaboration and teaming on safety and health projects, activities and goals are used to ensure involvement and
support from people in all areas.
n 1 n 2 n 3 n 4 n NS
3. Employee safety and health issues are a standard topic of discussion in all organizational meetings and an essential
consideration in all business decisions.
n 1 n 2 n 3 n 4 n NS

BWC-6625

SH-26

1 | Page

Workplace Wellness Grant Program

13

Attachment E2 OHBWC WWGP Overview and Forms

Rating scale: 1 = strongly disagree,

2 = disagree,

3 = agree,

4 = strongly agree,

NS = not sure

E.

Hazard prevention and control – The process to identify and correct unsafe acts and unsafe conditions
1. Employees at all levels are encouraged to promptly report safety and health hazards and unsafe acts to their supervisor
and/or safety contacts for follow-up action.
n 1 n 2 n 3 n 4 n NS
2. Safety inspections are performed regularly to identify unsafe acts, and conditions and hazards are effectively eliminated or minimized in a timely fashion.
n 1 n 2 n 3 n 4 n NS
3. New equipment, tools, materials, and methods are evaluated before purchase, implementation and use to ensure
that they do not create safety and health hazards
n 1 n 2 n 3 n 4 n NS

F.

Safety and health training and education – The process of making sure that safety education and training is provided to
people at all levels and that skills are assessed to ensure understanding
1. Individuals at all levels in the organization receive the appropriate level of job-specific safety training along with all
OSHA required training and a thorough explanation of the organization’s safety and health management process,
opportunities to participate, and expectations for performance.
n 1 n 2 n 3 n 4 n NS
2. Supervisors and managers are knowledgeable with regard to the potential hazards and the safe practices for all
jobs they oversee and are trained in safety observations, coaching and mentoring techniques to promote safe and
healthy work practices.
n 1 n 2 n 3 n 4 n NS
3. Employees are informed of all potential hazards in their jobs, provided with documentation of safe work practices,
and periodically evaluated to ensure understanding and compliance.
n 1 n 2 n 3 n 4 n NS

G. Accident analysis – The method of gathering and analyzing information and accident facts, determining root causes, and
identifying safety improvements to prevent future accidents
1. Supervisors document accidents, incidents and near misses, and conduct thorough accident analysis in a timely
manner.
n 1 n 2 n 3 n 4 n NS
2. Supervisors work with safety coordinators and employees to determine root causes of accidents and near misses
to ensure that effective corrective actions are taken.
n 1 n 2 n 3 n 4 n NS
3. Top management regularly reviews accident trends and workers’ compensation costs and uses the information to
help develop goals and objectives.
n 1 n 2 n 3 n 4 n NS
H.

Workers’ compensation claims management – The management process for ensuring timely filing of claims, care for the
injured workers, and minimizing the financial impact of claims on the organization
1. A clear and efficient process for reporting injuries/illnesses, obtaining medical treatment and filing the claim is
established and communicated to all employees and follow-up contacts are made with injured workers while they
are off work.
n 1 n 2 n 3 n 4 n NS
2. The person(s) responsible for managing workers’ compensation are knowledgeable about the various BWC rating
programs, discount programs and claims-management strategies and use them effectively
n 1 n 2 n 3 n 4 n NS
3. The person(s) responsible for claims management regularly consult with BWC, the MCO andTPA to monitor all open
claims, identify claims needing case management and rehabilitation services, and develop next steps to maximize
return-to-work outcomes.
n 1 n 2 n 3 n 4 n NS

I.

Return-to-work practices – The management process for ensuring a safe, efficient return to work by injured workers to
help reduce financial burdens on the employee and employer
1. The organization has developed policies and procedures for bringing an injured worker back to work in a safe and
timely manner and communicated them to all managers, supervisors, employees and local health-care providers.
n 1 n 2 n 3 n 4 n NS
2. The organization maintains a detailed inventory that quantifies the physical demands of its jobs and educates local
health-care providers on modified, transitional duty opportunities and expectations for releasing employees as soon
as medically suitable.
n 1 n 2 n 3 n 4 n NS
3. The organization collaborates with treating physicians and case managers and uses strategies such as job modifications, assistive devices and flexible work scheduling to facilitate placement of injured workers based on their
restrictions, capabilities and functional capacities.
n 1 n 2 n 3 n 4 n NS

BWC-6625

SH-26

2 | Page

Workplace Wellness Grant Program

14

Attachment E2 OHBWC WWGP Overview and Forms

Rating scale: 1 = strongly disagree,

2 = disagree,

3 = agree,

4 = strongly agree,

NS = not sure

J.

Employee health promotion (wellness) –The organization’s efforts to encourage personal health improvement and health
maintenance among its employees
1. Top management supports and actively participates in health and wellness programs and activities, and regularly
communicates the personal and organizational benefits.
n 1 n 2 n 3 n 4 n NS
2. Employees are encouraged to complete health risk assessments and are provided with data to help identify potential
health risks and improvement opportunities.
n 1 n 2 n 3 n 4 n NS
3. The employer provides low-cost/no-cost preventive care services and resources for health maintenance and health
improvement (e.g., health coaching, disease management, diet and nutrition counseling, smoking cessation, and
weight loss programs).
n 1 n 2 n 3 n 4 n NS

K.

Hazard identification - Please check all of the items below that apply to the nature of your business or the work operations.

n Elevated work with potential
for falls

n Trenching and excavation

n Exposure to chemicals or
hazardous substances

n Airborne contaminants
(dust, fumes, vapors)

n Moderate to heavy lifting,
carrying, push/pull

n Repetitive forceful exertions

n Exposure to electrical hazards
n Exposure to mechanical
hazards

n Confined spaces

n Elevated noise levels

n Sustained forceful exertions

n Power press, brake press,

n Earth-moving equipment

n Exposure to extreme heat

n Repetitive awkward work

n Knives, slitters, shears, other

n Forklifts or other powered

n Exposure to sunlight or other n Sustained awkward work

other powered trucks
trucks

n Cranes, rigging and material
lifting operations

or cold

UV radiation

n Needlesticks or other sharps

n Powered tools and/or powder n Bloodborne pathogens or
actuated tools

n Temporary traffic/roadside
worksite hazards

L.

other bodily fluids

postures

cutting tools

n Flammable or combustible

postures

materials

n Prolonged work at computer

n High-pressure gas cylinders,

n Vibration or impact forces on

n Welding, brazing, soldering,

terminal

the body

n Insect bites, stings, poisonous n Lifting and transferring
vegetation

forging press

propane, etc.

molten metal

n Slips/trips/falls

patients/residents

Please indicate which BWC safety and health programs and services you would like to learn more about.

n Safety consultation

n Safety and health training

n Safety and health videos/DVDs

n Industrial hygiene consultation

n Safety Congress and Expo

n Safety and health resource library

n Ergonomics consultation

n Safety council

n Safety grants

If you have any questions or would like to request personalized assistance from a BWC representative, call 1-800-OHIOBWC.
Employer’s signature

X

Completed by

BWC-6625

SH-26

Date signed

Job title

3 | Page

Workplace Wellness Grant Program

15

Attachment E2 OHBWC WWGP Overview and Forms

Workplace Wellness Grant Program Contract

AGREEMENT
Between the
Ohio Bureau of Workers’ Compensation
And
[Employer]
Whereas, the administ rator of w orkers’ compensation may issue a grant to defray the
costs of w orkplace w ellness programs incurred by an employer w ho elects to participate in
the Workplace Wellness Grant Program, pursuant to Ohio Administrative Code Rule (OAC)
4123-17-56.1, w herein an employer may receive grant monies for projects w hich
substantially reduce or eliminate t he risk of w orkplace injuries and illnesses through
addressing health risk f actors, called herein Workplace Wellness Grant Program.
Therefore, for good and valuable consideration, the sufficiency of w hich is acknow ledged,
the parties mutually agree to the follow ing conditions.
Distribution of grant monies — Subject to the conditions precedent in this agreement and
subject to available BWC resources, the employer and BWC mutually understand and agree
that the grant to be issued by BWC shall be paid to the employer according to the number
of participating employees for all four years of the Workplace Wellness Grant Program.
BWC shall aw ard grant funds for a maximum of 50 participating employees for each
employer. The employer shall be reimbursed according to the grant aw ard schedule
outlined in the Application for all f our years. Upon receipt of the data pertaining to the
completion of the healt h risk assessment of appraisal and biometric screening, BWC shall
disburse the grant aw ard of $100 for year one, $75 for year tw o, $75 for year three, and
$50 for year four per participating employee for each employer. BWC shall aw ard a
maximum of $300 per participating employee. The employer, whether a public or private
employer, agrees that the maximum grant amount shall not exceed $5,000 for year one,
$3,750 for years two and three, and $2,500 for year four, totaling $15,000 over the fouryear period. The employer must agree to assume the remainder of the costs of their
w orkplace w ellness program and that only participating employees shall be accounted for
w hen disbursing the grant aw ard. The employer understands and acknow ledges that BWC
w ill not issue a grant for any expenditures that exceed $15,000 over the four-year period.
Employer responsibilities — The employer participating in the Workplace Wellness Grant
Program, in consideration of a grant given to it, promises to fully comply w ith the program
requirements as outlined in the Application and Instructions and OAC 4123 -17-56.1, all of
w hich are fully incorporated herein by reference. The employer will be responsible for using
the awarded grant in the manner for which it is intended, and will be required to provide
BWC with documentation. This documentation may include, but is not limited to, original
invoices, canceled checks, and periodic reports to confirm that all funds were spent and
applied toward a wellness program. The employer must agree to use the funds to
compensate the wellness program vendor only and not as direct incentives to encourage
employee participation in the workplace wellness program. The employer also agrees to
allow BWC to publish w orkplace w ellness grant results including, but not limited to,
Workplace Wellness Grant Program

16

Attachment E2 OHBWC WWGP Overview and Forms

reports, literature, dat a, videos, specifications, and/or photos for the purposes of
illustrating, educating, and training employers and employees. In addition, the employer
must notify BWC if the agreement betw een the employer and w ellness program vendor
terminates at any time during the four-year program. The employer must also agree to seek
a different w ellness program vendor. Once the employer enters into an agreement w it h a
different w ellness program vendor, the employer must notify BWC.
If the employer chooses to not renew its application for the Workplace Wellness Grant
Program and therefore discontinue its participation w ith the program, the employer must
still submit a year-end case study.
If suspicious activities surrounding the employer’s reporting scheme arise, as judged by
BWC in its sole discretion, BWC reserves the authority to inspect the employer’s files
pertaining to the employer’s participation in the Workplace Wellness Grant Program.
Conditions precedent to receipt of grant funds — The receipt of grant funds for all four
years is subject to the following conditions precedent:
1. Wellness program vendor: After the submission of this Applicat ion and Agreement ,
the employer must obtain an agreement bet w een it and a third-party w ellness
program vendor. A copy of the agreement betw een the employer and w ellness
program vendor must be submitted along w ith the required data elements.
2. Application and Agreement : The employer must submit the original signed and
dated copies of the Application and this Agreement.
3. Health risk appraisal and biometric screenings: Upon the date of approval for t his
Application and its subsequent renew al for years tw o through four, the employer
shall have three months to administer a healt h risk assessment or appraisal AND
biometric screening for its employees. Administering the health risk assessment or
appraisal and biometric screening shall be completed by w orking w it h the w ellness
program vendor.
4. Required data elements and names and claim numbers associated w it h participating
employees: Upon completion of the health risk appraisal or assessment and the
biometric screening, t he employer must report the required data elements in
aggregate form as listed in the Application. The names and claims data of all the
participating employees shall also be report ed. The employer shall have three
months to complete this condition.
Time of performance — Within three months of the date of grant approval, the employer
will be required to electronically provide BWC its requested data elements, claim numbers
that are associated with participating employees, and a narrative. For year one, the
employer shall also provide a narrative case st udy at the time of applying for the grant.
One year after the date BWC receives the required data elements and names and claims
data pertaining to all participating employees, t he employer may renew its receipt of funds
for participating in of the Workplace Wellness Grant Program.
Workplace Wellness Grant Program

17

Attachment E2 OHBWC WWGP Overview and Forms

In order to obtain funds for years tw o through four, the employer must submit a case
study that describes the previous year’ s activities, the previous year’ s required data
elements, and the names and associated claim data of the current year’ s participating
employees. The aforementioned information must be submitted one year from the date of
the previous grant check being issued to t he employer. If the employer chooses to
discontinue its participation in the Workplace Wellness Grant Program, BWC will require
notification that details the reasoning behind the decision. The employer must remit any
grant funds awarded from BWC during its participation in the Workplace Wellness Grant
Program. An employer may not reapply for the Workplace Wellness Grant Program once it
withdraws.
Within three months of reporting the required data elements, participating employee data,
and narrative or case study, the employer will be required to provide BWC a copy of the
approved budget and itemized expense report, original paid invoices/receipts pertaining to
paying the wellness program vendor for its services, and copies of all cancelled checks to
support that all invoices associated with the Workplace Wellness Grant Program were paid
in full.
Disqualification — If for any reason the employer part icipating in the Workplace Wellness
Grant Program fails to satisfy one or more of the criteria established in the Application and
Instructions, OAC 4123-17-56.1, and this agreement, including, but not limited to, t he
requirement of maintaining active coverage, t imely payments thereof , and the obligations
described in the Employer Responsibilities and Time for Performance sections, the employer
may be disqualified from the program. Disqualification will result in the termination of
BWC’s obligations under this agreement. BWC reserves the right to recover grant monies
by one or more of the following methods: billing the employer for the grant money
received, forwarding the employer’s information to the Office of the Attorney General of
Ohio for collection, set-off, recoupment, or other administrative, civil and/or legal remedy.
If the employer merges or combines its business after receiving a grant, but before
completing the four years of measurement reporting, the BWC Successorship Liability
Policy w ill go int o effect. The grant /predecessor employer is responsible for notifying the
successor employer of the obligations under t he Workplace Wellness Grant Program. The
successor employer may be liable to repay any and all previously paid grant monies if these
obligations are not met.
Disclaimer — If implemented correctly by the employer, the goal of the Workplace
Wellness Grant Program is to substantially reduce or eliminate injury and illness in the
w orkplace through addressing health risk factors and, hence, claims associated w ith the
participating employees. BWC does not guarantee or w arrant that t he implementation of
such a plan w ill result in a substantial reduction or elimination of injuries and illnesses in
the w orkplace. In the event of an injury or occupat ional disease arising from the
implementation of the program, the employer and the employee’ s sole and exclusive
remedy shall be pursuant to w orkers’ compensation law s of the appropriate jurisdiction. In
no event, shall BWC be liable for any damages in contract or in tort . BWC shall also not be
liable for any damages in contract or in tort that may occur from t he agreement betw een
the employer and w ellness program vendor.
Workplace Wellness Grant Program

18

Attachment E2 OHBWC WWGP Overview and Forms

Ohio elections law — Grantee hereby certifies that no applicable party listed in Divisions (I),
(J), (Y) and (Z) of Ohio Revised Code (ORC) Section 3517.13 has made contributions in
excess of the limitations specified under Divisions (I), (J), (Y) and (Z) of ORC Section
3517.13
Conflicts of interest and ethics compliance certification — Grantee affirms that it presently
has no interest and shall not acquire any interest, direct or indirect , w hich w ould conflict,
in any manner or degree, w ith the performance of services w hich are required to be
performed under any resulting Contract. In addition, Grantee affirms that a person w ho is
or may become an agent of Grantee, not having such interest upon execution of this
Contract shall likew ise advise BWC in the event it acquires such interest during the course
of this Contract. Grantee agrees to adhere to all ethics law s contained in Chapters 102 and
2921 of the ORC governing ethical behavior, understands that such provisions apply to
persons doing or seeking to do business w ith BWC, and agrees to act in accordance w ith
the requirements of such provisions; and w arrants that it has not paid and w ill not pay, has
not given and w ill not give, any remuneration or thing of value directly or indirectly to BWC
or any of its board members, officers, employees, or agents, or any third party in any of
the engagements of this Agreement or otherw ise, including, but not limited to a finder’ s
fee, cash solicitation fee, or a fee f or consulting, lobbying or otherw ise.
Grantee, by signature on this document, certifies that Grantee: (1) has reviewed and
understands the Ohio ethics and conflict of interest laws, and (2) will take no action
inconsistent with those laws and this order. The Vendor or Grantee understands that
failure to comply with the Ohio ethics laws is, in itself, grounds for termination of this
contract or grant and may result in the loss of other contracts or grants with the State of
Ohio.
Non-Discrimination and Equal Employment Opportunity — The Grantee w ill comply w ith all
state and federal law s regarding equal employment opportunity and fair labor and
employment practices, including ORC Section 125.111 and all related Executive Orders.
The State encourages the Grantee to purchase goods and services from Minority Business
Enterprise (MBE) and Encouraging Diversity, Grow th and Equity (EDGE) vendors.
Authority — The person signing below f or the employer states that he or she is either the
ow ner, chief executive officer, chief financial officer, plant manager or other person having
fiduciary responsibilities w ith the employer; and the employer agrees t hat that the signer or
his, or her successor, w ill have the authority to oversee the carrying out the employer’ s
responsibilities for all f our years that BWC issues the grant checks. The signer’ s authority
shall continue until the employer notifies BWC of the name of the successor.
By initialing this box, the employer agrees that it does not have an
existing w ellness program in place, as defined by this Application. The employer also
agrees that it does not have an agreement w ith a w ellness program vendor that has
commenced prior to Feb. 6, 2012. The employer also confirms understanding that any
changes pertaining to t he w ellness program vendor must be communicated to BWC.

Workplace Wellness Grant Program

19

Attachment E2 OHBWC WWGP Overview and Forms

Effective Date — The effective date of this Agreement is the latest date indicated below
the parties' respective signatures.
Employer Tax ID

State of Ohio,
Bureau of Workers’ Compensation

BWC Policy (Risk) number
Signature

Signature

Name

Name

Title

Title

Date

Date

Workplace Wellness Grant Program

20

Attachment E2 OHBWC WWGP Overview and Forms

Requirements for annual case study

The case study will be due one year from the date BWC
warranted the grant check. The purpose of this case study
is to assess safety, wellness, and claims management
and to assist with establishing best practices for the
implementation of workplace wellness programs.
Completion and a timely submission of the case study is
required to receive funding for the next year. The following
information needs to be included in each case study.

Employer information
o Company name
o Number of employees who participated in the
wellness program (include employees who completed
the biometric screening, completed the health risk
appraisal (HRA) and participated in at least one program)
o Number of employees in the company (total)
o Absenteeism and turnover rates
o Occurrence of workers’ compensation claims amongst
employees participating in the wellness program
o Current health-care utilization costs

Wellness program information

o Description of your wellness program for the past year
• Discuss aggregate results from HRAs and
biometrics
• Wellness training provided and attendance rates
• Wellness coaching provided and participation rates
o What went well?
o What challenges did you face this year regarding your
wellness program?
o Are you incorporating wellness into your company
culture? How so?

o Have you been able to follow the “Elements to
implementing an effective wellness program” If not,
what are the steps you eventually followed? Below is
a list of the elements.
• Obtain senior leadership commitment.
• Develop a written wellness program.
• Include a wellness plan in the business operations
plan.
• Develop a wellness team or appoint a wellness
coordinator.
• Collect data through surveys and screenings.
• Identify and deliver health promotion programs and
services which will benefit your workers based on
surveys and screenings.
• Continuously evaluate and improve the program.

Additional information needed to receive
funding for next year

oo Have you scheduled the biometric screening and HRA
for the next year?

__yes
__no

This information must be turned in to BWC within the
first three months of the participating program year to
receive funds.
oo Are you remaining with the same wellness program
vendor for next year’s wellness grant program
participation? If so, please provide us with a copy of
the renewal contract. If not, please provide us with a
contract from your new vendor.
oo What are your goals for next year?

Workplace Wellness Grant Program

21