THE WEIGHT LOSS FIRM
APPLICATION
Due
December 2012
*
Name of Business
(Please include specific location or store number if there is more than one location):
*
Number of Employees:
 1-25
101-500
501-999 1000+ | | | | |
Type of Business:
Profit
Not for Profit |
*
Please enter the following information:
Contact Person: | |
Address: | |
City/Town: | |
State: |
|
ZIP: | |
Email Address: | |
Phone Number: | |
1. Check the screenings/evaluation and preventive
programs
your workplace provides:
0 free or reduced
cost annual physical exams for employees 0 cardiovascular fitness evaluation 0 cholesterol screening 0 blood pressure screening
0 body fat evaluation |
2. Check the health education, promotion materials your company provides:
0
posted printed material
0 newsletters 0 health topics in electronic media 0 paycheck stuffer or health topics covered at employee
meetings
0 offers items in this category to family member 3. Check
all physical activities offered by your company. |
0 offers exercise activities (walking, step aerobics, exercise videos, etc.) 0 fitness room/equipment 0 off-set the cost of off-site fitness center memberships 0 offers organized team sports (softball, soccer,
etc.) 0 provide pedometers 0 provide breaks/time off to exercise 0 offers items in this category to family members 0 sponsors individual employee participation in
athletic/fitness events |
4. Check all programs and information related to Weight Loss
provided by your workplace.
0 offer healthy vending machine selections (fruit juices, salads,
pretzels, low-fat yogurt, etc.) 0 offers payroll deduction plans 0 post nutritional information in break areas
0 offers Medical Weight Loss program
0 offers items in this category to family members 0 offers accountability and support |
5. Check the management support your workplace receives
to promote employee health and safety:
0 provides space for breastfeeding mothers 0 incentive programs/contests 0 offer health insurance to employees at no/reduced cost 0 employee support groups 0 health/wellness committees in place 0 offers Weight Loss Coaching and medical supervision 0 onsite occupational safety program (lifting, defensive driving, etc.) 0 onsite disease management program
0 onsite behavioral health program (stress management, work/life
balance, depression, etc.)
0 provides CPR/AED certification opportunities
0 offers items in this category to family members 0 offers medical/clinical services (ex. onsite clinic or visiting
nurse, etc.) |
6. Check the ways your company involves the
community in health & wellness
0 invites other groups or
companies to participate in the physical activities offered by your company 0 conducts screenings/evaluations to at risk groups in the community 0 supports blood donor programs 0 offers items in this category to family members |
7. Wellness Policies
Implemented
0 implemented Weight Loss policy 0 implemented physical activity policy 0 implemented worksite safety policy (texting
while driving, seat belt use, etc.)
0 implemented tobacco free policy
***** |
To help promote and encourage a 5 star rating for Weight Loss,
all companies/workplaces seeking
to achieve the highest level of certification
(TCHE) must have 100%
of their employees < 30 BMI
BE SURE YOU HAVE:
- Completed ALL questions in the application
- Send only one application (Do NOT
submit online and hard-copy)
- Correct
addresses, e-mail and mail
- Legible
writing on hard copies
- Complete
name of business
- Checked
all items that apply to your business
PLEASE
• Read Future E-Mails Related to Tennessee
Certified Health Excellence
Thank you for your participation. To submit this form in hard copy,
simply
print these pages and mail or fax the completed form no later than
December 31st, 2012.
The Weight Loss Firm,
6231 Perimeter Dr
Suite 113
Chattanooga Tn 37421
423 475 5088 or fax 423 899 0110
