Application for Workplace Wellness Grant Program Instructions Complete all fields in this application. BWC cannot process incomplete applications. An officer, partner or owner must sign this application. Obtain and complete the following forms from Ohio Shared Services by logging on to http://ohiosharedservices.ohio.gov/SupplierOperations/Forms.aspx: Supplier Information form; direct deposit form; and W-9 tax form. Mail the completed forms to Ohio Shared Services, P.O. Box 182880, Columbus, Ohio 43218-2880. If you have questions, call 1-877-644-6771. Complete the Safety Management Self-Assessment (SH-26) online if you have not completed it within the last year. The assessment is available by logging on to www.bwc.ohio.gov/employer/forms/SafetyMgtSelfAssessment/Default.aspx. Download and sign the Workplace Wellness Grant Program contract. Access the contract by logging onto www.bwc.ohio.gov/employer/programs/safety/WellnessGrants.asp. Mail the signed contract to the address below. Employer information Name of employer and DBA Address City State ZIP code Federal tax ID number BWC policy number Contact information for Wellness Grant Program Employer contact name Title Phone number (with extension) Fax number Email address Eligibility requirements You must complete the items below for BWC to determine workplace wellness grant eligibility. 1. Do you currently have a wellness program using a health-risk appraisal (HRA) and a biometric assessment both of which measure health-risk factors? Yes No 2. Do you currently have a wellness program with health promotion programs and activities (such as health coaching, walking challenges, etc.) that are designed to address the health-risk factors for appraisal and biometric? Yes No BWC-6626 (Rev. March 7, 2016) Pag e |1 American LegalNet, Inc. www.FormsWorkFlow.com SH-27 Application for Workplace Wellness Grant Program Industry type/Total employee information Employer industry Total number of employees Budget You may use the workplace wellness grant for items such as HRAs, biometric screenings, awareness training, healthcoaching services and the development of a workplace wellness program. You may NOT use the workplace wellness grant funds for employee incentives, recouping the cost of any prior and/or ongoing wellness program or fitness/exercise equipment. In addition, you may not use workplace wellness grants to pay for salaries, wages, internal labor or any costs associated with preparing the application. Please provide the estimated budget for your wellness plan. Type of service Estimated cost Narrative All other answers require an explanation. Employer profile 1. Provide a description of your organization and business. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ BWC-6626 (Rev. March 7, 2016) Pag e |2 American LegalNet, Inc. www.FormsWorkFlow.com SH-27 Application for Workplace Wellness Grant Program 2. What difficulties have you encountered in the past when trying to implement wellness in your company? Lack of financial resources Union contract restrictions Lack of human resources Lack of awareness regarding benefits Low to no return-on-investment High absenteeism/turnover Lack of upper-management support Remote work locations Low employee interest or participation Never tried to implement a wellness program before Concerns about legal issues No difficulties Concerns about confidentiality of health data Other: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3. Have your employees completed a HRA within the last 12 months? Yes. Please check at least one. Explain who provided the service and how the information was used. Spouse's insurance Vendor Health fair, other carrier Health fair, workplace Insurance carrier Primary care physician Other: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How was this information used? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ No 4. Have your employees completed a biometric screening within the last 12 months? Yes. Please check at least one. Explain who provided the service and how the information was used. Vendor Health fair, other Spouse's insurance carrier Health fair, workplace Insurance carrier Primary care physician Other: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How was this information used? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ No BWC-6626 (Rev. March 7, 2016) Pag e |3 American LegalNet, Inc. www.FormsWorkFlow.com SH-27 Application for Workplace Wellness Grant Program 5. What wellness program elements have been in place over the last 12 months? Identify all that apply. Physical fitness component (e