WORKSITE WELLNESS LEAVE PARTICIPATION REQUEST (A NEW REQUEST AND

WORKSITE LEARNING CHECKLIST COMPLETE THE FOLLOWING AND
13 NCAC 07A 0602 DEFINITIONS (A) FIXED LOCATION WORKSITE
“ WORKING ON WELLNESS ”IN WAUPACA COUNTY EMPLOYER WORKSITE

B SUPERVISOR MENTOR‘S‘ SURVEY OF WORKSITE PROGRAM LANK BLANK
COMMUNITY SERVICE WORKSITE AGREEMENT (PHA NAME AND ADDRESS) THIS
FIELD AUDIT & QUALITY WORKSITE INSPECTION REPORT WORK INSTRUCTION

(Recreational Sports / Wellness Center Letterhead)



WORKSITE WELLNESS LEAVE PARTICIPATION REQUEST

(A new request and documentation must be submitted each year.)


MSU Policy 3.350, Worksite Wellness Program

Eligible employees may be granted eight hours of additional leave time to be used within a 12 month period. Wellness Leave must be used as one eight-hour increment. It does not accrue and is not paid upon separation from MSU. Employees wishing to participate must provide proof to the Coordinator of Wellness Programs of a physical examination by a health care provider within the last 90 days. Use of Wellness Leave must be scheduled in advance with the approval of the employee’s supervisor. Functions of the University take priority in scheduling leave. Recordkeeping will be handled by the Wellness Center and Payroll. Wellness Leave is recorded on the staff employee’s timesheet in the “Emergency-Off Duty Hours” column with “Wellness Leave” notated. Part-time staff will receive prorated leave hours.

TO BE COMPLETED BY THE EMPLOYEE: (Please Print or Type)


Employee: _____________________________ Title: ___________________________


Department: _______________________ Supervisor: __________________________


Pursuant to MSU Policy #3.350, I hereby request to be granted eight hours of Wellness Leave. I understand that the leave must be used with the approval and prior knowledge of my supervisor and must be used as one 8-hour increment or a prorated number of hours for eligible part-time staff.


Employee’s Signature: _________________________ Date: _____________________

TO BE COMPLETED BY COORDINATOR OF WELLNESS PROGRAMS:


Is employee eligible? ___ Yes ___ No (If no, return form to employee)

If yes, complete below:


I certify that the employee has completed the Health Risk Assessment and provided documentation of a physical examination by a health care provider within the last 90 days.


_____ Hours of Wellness Leave is granted effective ____________________________ (Leave must be used within 12 months from this date or will be forfeited.)


_____________________________________________ Date: __________________

Signature: Coordinator of Wellness Programs


(Original: Wellness Center / Copy: (1) Payroll - (2) Supervisor – (3) Employee)


MISSOURI MENTORING PARTNERSHIP WORKSITE PROGRAM REFERRAL PROCESS & INFORMATION
N NO 000001 OFO03011 WORKSITE LOG AND DIARY WORKSITE
NORTH DAKOTA WORKSITE WELLNESS PROGRAM REQUEST FORM 20142015 THANK


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