HR Vitality Plan Template

HR Vitality Plan Template

Employee Name:   Employee ID:

Plan Creation Date:   Plan Period Start:   Plan Period End:

Personal Information

Position Information

Employment History (Most Recent Two Employers)

Education

References (Professional)

Baseline Health & Assessment Metrics

Assessment Date:

Weight (lbs):   BMI:   Blood Pressure:

Cholesterol (Total):   Fitness Assessment Notes:

Vitality Goals & Targets

Employer Support / Resources

Available supports (check applicable):
Gym membership subsidy    Nutrition counseling    Mental health services    Flexible schedule for activities

Milestones & Review Schedule

Confidentiality, Data Use, and Consent

All personal health information and assessment data collected under this Vitality Plan shall be treated as confidential. Data will be used solely to administer the employee's wellness plan, measure progress toward stated goals, and to determine eligibility for employer-provided wellness incentives. Aggregated and de-identified summaries may be used for program evaluation without disclosure of personally identifiable information.

By initialing and checking the consent box below, the employee authorizes the employer and designated wellness vendors to collect and process the health data necessary to implement this plan and to discuss results with the employee and the employee's authorized health care providers as needed for plan administration.

Employee initials:    Consent to participate:

Legal Notices & Disclosures

At-Will Employment: Participation in this Vitality Plan does not alter the at-will employment relationship. Either the employee or the employer may terminate employment at any time, with or without cause or notice, unless otherwise required by law or a signed written agreement.

Equal Opportunity: The employer maintains an equal employment opportunity policy. Participation in this plan is voluntary and will be administered in a nondiscriminatory manner consistent with applicable law.

Release and Liability: The employee acknowledges that participation in wellness activities may involve risk. The employer will exercise reasonable care in program administration but is not liable for personal injury arising from participation except to the extent required by applicable law. The employee agrees to notify a health care professional if uncertain about participation in any activity.

Authorization to Contact and Background Acknowledgment

The employee authorizes the employer to contact prior employers and references provided in this form for purposes consistent with employment verification and wellness program administration. The employee understands that background checks or fitness-for-duty assessments may be required by policy and consents to such checks where permitted by law.

Employee certification: I certify that all information provided in this Vitality Plan Template is true and complete to the best of my knowledge. I understand that providing false information may result in disciplinary action up to and including termination.

Modification and Termination of Plan

This Plan may be modified by mutual written agreement between the employee and the employer representative. The employer reserves the right to suspend or terminate the Vitality Plan for administrative or legal reasons, or if the employee fails to comply with agreed milestones. Any incentives tied to the plan will be administered in accordance with the employer's policies.

Accommodations & Reasonable Adjustments

If the employee requires reasonable accommodation to participate in program activities due to a disability or medical condition, the employee should notify Human Resources. Reasonable accommodations will be considered consistent with applicable law and the employer's accommodation policies.

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