Item C02 } C.2
`,
Coin of Monroe
�y,4 ' �, "tr, BOARD OF COUNTY COMMISSIONERS
County Mayor Heather Carruthers,District 3
�1 `ll Mayor Pro Tem Michelle Coldiron,District 2
The Florida Keys ` )-.���` Craig Cates,District 1
David Rice,District 4
w � Sylvia J.Murphy,District 5
County Commission Meeting
September 16, 2020
Agenda Item Number: C.2
Agenda Item Summary #7249
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Natalie Maddox (305) 292-4450
N/A
AGENDA ITEM WORDING: Approval of a resolution approving and establishing the 2021
Wellness Program and funding levels, which includes health and wellness events (lunch and learns,
health and wellness fairs, exercise and nutrition classes), wellness exam and age-appropriate
screenings with a participation incentive that includes a tobacco cessation plan, community
organized event reimbursement (walks, runs, bikes, swims), and Approval of the 2021 Wellness
Funding. Also provides for four hours of annual leave to Monroe County BOCC employees and
participating Constitutional Officer (Property Appraiser, Court Administration, Land Authority and
Clerk of Court) employees who participate in the annual Health & Wellness Fair (minimum
participation of biometrics and health coach visit) or visit their personal physician and complete the
online Personal Health Assessment. Due to the COVID-19 pandemic, this also allows for Wellness
Events to be held online/virtually.
ITEM BACKGROUND: The goal of the Wellness Program is to encourage healthy lifestyle
choices in the interest of disease prevention and provide opportunities for early detection of illnesses
before major medical treatment is required. This contributes to a healthier workforce and seeks to
reduce long-term medical and pharmacy claims cost.
As part of the County's agreement renewal with Florida Blue in 2018, Florida Blue paid the County
a $50,000 wellness contribution upon BOCC approval of the agreement renewal; a $50,000 wellness
contribution was made on January 1, 2019, and is due again on January 1, 2020; January 1, 2021;
January 1, 2022 and January 1, 2023 per the agreement. The County has implemented programs
from 2011-2019 using funds from Florida Blue to encourage health plan enrollees to participate in
wellness programs and educational opportunities.
The 2021 program includes:
All wellness program opportunities will be administered either virtually or onsite, depending upon applicable
future safety guidelines for COVID-19.
Recurring Events:
• Community Organized Event Reimbursement up to $100 annually per enrollee for
participation in marathons, walkathons, etc.
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C.2
• Lunch and Learns (Topics will address the top 4 risk areas: Diabetes, BMI, Nutrition,
Blood Pressure)
• Health and Wellness Fairs
• Funding of exercise (Yoga, Zumba, etc.) and nutrition classes (healthy cooking, etc.)
held at Government Centers (Lower, Middle and Upper Keys)
• Wellness Champion Visits/Virtual Presentations by Staff(Will address the top 4 risk
areas: Diabetes, BMI, Nutrition, Blood Pressure). *Due to COVID-19, the department
suspended the services of Health Designs, Inc., who provided in-person health and wellness
education at County and Constitutional office locations.
Health &Wellness Rewards:
• Annual Wellness Exam and Age Appropriate Screenings: Participating employees on the
traditional Health Plan will receive $ 25.00 per month ($300 per year)premium discount in
2022. Participating employees on the High Deductible Health Plan with Health Savings
Account(HDHP/HSA) will receive $300 deposited into their Health Savings Account in
2021. Employees who attest to tobacco use are included in the ability to earn the employee
health insurance premium discount. To be eligible, in addition to the age appropriate
screenings required for all participants, those attesting to tobacco use, must voluntarily
participate and complete at least one approved tobacco cessation program during the wellness
program period of the prior year (November 1, 2020— October 31, 2021) and submit a
certificate or letter of participation/completion from the facilitating program. List of
approved tobacco cessation program(s)to be maintained by Employee Benefits and regularly
communicated to employees during Wellness Champion visits.
• Annual Biometric Screenings and Online Personal Health Assessment: BOCC and
participating Constitutional Officer(Property Appraiser, Court Administration, and Land Authority
employees (those covered and not covered by the County Health Insurance)who:
A. Attend the annual Health Fair and participate in biometric, blood pressure, cholesterol,
blood sugar level and body mass index screenings
OR
B. Visit their personal physician and obtain biometric, blood pressure, cholesterol, blood
sugar level and body mass index screenings (on or between the dates of I I/1/20 to
10/31/21) and complete the on-line personal health assessment by 2/1/22.
*Will receive 4 hours of personal time off. *Only approved by BOCC, Clerk of Courts,
Land Authority and Property Appraiser for their employees.
ALTERNATE(Virtual): Outlined in Section D of Wellness Program Resolution.
Purchases of Goods:
• Gato Building Gym — The Gato Fitness Center opened on May 14, 2018. Up to
$5,000.00 annually shall be planned for equipment maintenance, repair, and
replenishment of fitness center supplies.
The table below demonstrates preventive screening participation for 2019. In the attached
Preventive Screenings Historical Data,participation during 2016 —2019 can be viewed.
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C.2
PREVENTIVE SCREENINGS 2019
2019'
2019 TOTAL 2019 Employee Employee
EMPLOYERS EMPLOYEES Participation Percentage
MC SHERIFF OFFICE 499 137 27%s
COUNTY CLERK 71 48 67%
TAX COLLECTOR 54 27 50%
PROPERTY APPRAISER 38 22 60%'
SUPERVISOR OF ELECTIONS 8 7 90%'
COURT ADMINISTRATION 21 9 45%
LAND AUTHORITY 3 3 100%
BOARD OF COUNTY COMMISSIONERS 520 226 43%
Total 1214 479 39%i
2016 total participation was 108 of 1236 total eligible employees, or 8.7%.
2017 total participation was 688 of 1235 eligible employees, or 56%.
2018 total participation was 480 of 1245 eligible employees, or 38%.
2019 total participation was 479 of 1214 eligible employees, or 39%.
(Attached file: Preventative Screenings)
Florida Blue reports that the County has spent approximately $2,182,000.00 in claims on
Wellness screenings over a 5-year period (October 2014 — September 2019). For the same
period Florida Blue estimates that the initiatives of the Wellness Program are approaching a
savings to the plan of over 8.5 million dollars (as cost avoidance). Based on this estimate, every
$1.00 spent on Wellness Preventative Screenings saves $6.00 as avoided claims cost. (Attached
file: Florida Blue 5-year wellness claims cost and estimated ROI)
Florida Blue suggests that the 4 top risk areas for the County are:
1) Diabetes
2) Obesity/Body Mass Index (BMI)
3) Cancer
4) Blood Pressure/Cardio-Pulmonary Disease
Budget
The FY2020 program has an ending balance of$ 116,992.00. The program is scheduled to
receive $50,000 from Florida Blue in the first quarter of CY2021,per agreement. Total CY2021
beginning balance: $166,992.00.
Recap:
Budget
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C.2
The FY2020 program has an ending balance of$ 116,992.00. The program is scheduled to
receive $50,000 from Florida Blue in the first quarter of CY2021,per agreement. Total CY2021
beginning balance: $166,992.00.
Recap:
$ 545K is the cumulative revenue of the program since the beginning, and $ 334K is the
cumulative expenses.
Using round numbers, $ 545K - $ 334K= $ 211K available to spend in 2020.
$ 210,992 minus the $ 44,000 that we plan to spend in 2020 = $166,992 (the 2021 beginning
balance). Then, we anticipate spending approximately 50k in 2021 which will take the $166,992
down to $ 116,992, which is the forecasted ending balance for 2021.
Total expenses for the 2021 program are planned at approximately $ 45,000.00.
PREVIOUS RELEVANT BOCC ACTION:
Resolution 267-2019 —2020 Wellness Program and Funding
Resolution 262-2018 —2019 Wellness Program and Funding
Resolution 027-2018 —2018 Wellness Program and Funding
Resolution 049-2017 —2017 Wellness Program
Resolution 173-2017 —2017 Wellness Program Funding
CONTRACT/AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: Approval.
DOCUMENTATION:
Wellness Resolution for 2021 8 27 20
2021 WELLNESS PHYSICIAN FORM
2020 Preventive Care Guidelines
Preventive Screenings
Florida Blue 2014 -Present Wellness Claims Cost& Est ROI
Wellness Funding 08 20
FINANCIAL IMPACT:
Effective Date: l l/l/2020
Expiration Date: 10/31/2021
Total Dollar Value of Contract: N/A
Total Cost to County: $45,000.00 estimated
Current Year Portion: $45,000.00 estimated
Budgeted: Wellness Program Funds
Source of Funds: Florida Blue Wellness Contribution,per contract
CPI: N/A
Indirect Costs: 4 Hours annual leave per employee who participates in the Personal Health
Assessment
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C.2
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: N/A
Additional Details: The program is scheduled to receive $50,000 from Florida Blue in the first
quarter of CY2021,per agreement. Total CY2021 beginning balance is expected to be:
$116,992.66
Total expenses for the 2021 program are planned at approximately $45,000.00.
Approximately $ 45,000.00 for the 2021 program to be spent from the existing Wellness
Program Budget, and less if expenditures if all or portions of the program are virtual.
REVIEWED BY:
Bryan Cook Completed 08/28/2020 8:45 AM
Natalie Maddox Completed 08/28/2020 8:53 AM
Cynthia Hall Completed 08/28/2020 9:51 AM
Assistant County Administrator Christine Hurley Completed
08/31/2020 10:30 AM
Purchasing Completed 08/31/2020 10:39 AM
Budget and Finance Completed 09/01/2020 1:28 PM
Maria Slavik Completed 09/01/2020 1:30 PM
Kathy Peters Completed 09/01/2020 1:36 PM
Liz Yongue Completed 09/01/2020 1:55 PM
Board of County Commissioners Pending 09/16/2020 9:00 AM
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C.2.a
RESOLUTION NO. -2020
A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA APPROVING AND
ESTABLISHING THE CALENDAR YEAR 2021 WELLNESS
PROGRAM; REPEALING PRIOR RESOLUTION NO. 267-2019 AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, beginning in 2015, the contract between Blue Cross Blue Shield of Florida
("Florida Blue")and the County,whereby Florida Blue serves as the Administrative Services Only ,
administrator(ASO)for the County's self-insured health insurance plan("Plan")has provided that
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Florida Blue will contribute an annual amount toward the County's wellness-related initiatives and
activities, consisting of $100,000 at execution of the agreement, $75,000 on each of January 11
2016 and January 1, 2017, with additional contributions of $50,000 on January 1, 2018. Upon ,
execution of a renewal contract between Blue Cross Shield of Florida dated September 19, 2018
and the County, a contribution of $ 50,000 was made toward the County's wellness-related N
initiatives and activities, and $50,000 was contributed January 2019 and January 2020. $50,000
is due to be contributed to the County in January of 2021, 2022 and 2023,per agreement; and 0
WHEREAS, currently, the balance of funds contributed by Florida Blue toward wellness
programs shall stand at approximately $ 116,992.00 ("Wellness Fund") for 2020; and
WHEREAS, the County has received the results from the personal health assessments
completed by the fall 2015, 2016, 2018, 2019 health fair participants (2017 Health Fair canceled T
due to Hurricane Irma), and the results indicate that the top four at-risk areas for participants are
diabetes, hypertension/cardio-pulmonary disease, cancer, and obesity; and
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WHEREAS, it is in the best interests of Plan participants and the plan that Monroe County co
adopt a coordinated program designed to improve and promote the health of its Plan participants
through early assessments, intervention, education, information, and incentives, particularly
targeted against the top four at-risk areas for health fair participants; and 0
WHEREAS, the County desires to use the Wellness Fund on the activities described 0
below.
NOW THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF MONROE COUNTY, FLORIDA that:
1. In calendar year 2021,the Monroe County Wellness Program shall consist of the following
items, which shall be paid for from the Wellness Funds contributed by Florida Blue E
pursuant to its contract with Monroe County and the existing Wellness Fund. All such
purchases must be finalized within calendar year 2021.
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C.2.a
Recurring Events:
a. Community Organized Event Reimbursement: All employees covered under the
County's health insurance plan are eligible to be reimbursed their registration fees
in an amount not to exceed one hundred dollars ($100.00) annually upon 6
presentation of proof that the individual has registered for and has completed
community organized foot, bicycle, or swimming race that takes place in the
Florida Keys, including but not limited to marathons, triathlons, run/walkathons,
and bikeathons. Said requests for reimbursement shall be handled on a"first
come first served" basis. Planned cumulative expenditure of two thousand dollars E
($2,000.00); if events are held due to COVID-19. All request for reimbursements
must be submitted to the Employee Benefits Department no later than January 11,
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2022. y
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b. "Lunch and Learn": (Virtually or onsite, depending upon applicable future safety
guidelines for COVID-19) The County's Benefits office will schedule education
"lunch and learn" activities throughout the Florida Keys, twice per year, offering
presentations on a variety of wellness topics. If onsite, staff will purchase healthy
food items for consumption by active employees who attend and complete
scheduled activities. The expenditure of Wellness Funds under this resolution shall 0
not exceed thirteen dollars ($13.00)per individual per meeting.Planned cumulative
expenditure for all Lunch and Learn events is five thousand dollars ($5,000.00);
will be less if virtual.
c. Wellness and Exercise Classes: (Virtually or onsite, depending upon applicable T
future safety guidelines for COVID-19) Wellness Funds will be used to provide
free wellness, exercise, and nutrition classes for employees and their dependents
over age 18 covered under the County's health insurance plan. The classes and
events will consist of different types of wellness and exercise, including but not co
limited to Yoga, Zumba and Pilates, and nutrition/healthy cooking classes. These
classes will be held at various County buildings with external instructors.
Wellness Funds will be used to compensate the instructors and purchase supplies. 0
The planned cumulative expenditure for Wellness Funds used on all Exercise o
Classes during CY 2021 is fifteen thousand dollars ($15,000);will be less if virtual.
0
d. Annual Health & Wellness Fair: (Virtually or onsite, depending upon applicable
future safety guidelines for COVID-19) Each year,Monroe County Benefits office
coordinates the Monroe County Health & Wellness Fair. The fair is presented in
three (3) locations (Upper, Middle and Lower Keys/Key West). Any active
employees of any of the employers participating in the Plan and their covered
dependents over age 18, retirees and their covered dependents over age 18 may
attend.
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C.2.a
Health Fair and Health Assessment Participation
Year Health Fair Participants Online Health Assessment
2015 335 32
2016 369 29
2017 Hurricane Irma- canceled Hurricane Irma- canceled
2018 326 17
0
2019 340 9 CL
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2020 will feature a first ever Virtual Health & Wellness Fair October 5, 2020 —
October 11, 2020. Presentations by Monroe County Employee Benefits, Florida C44
Blue, Capital Rx, Delta Dental, VSP, Quantum (EAP), and Minnesota Life will be 0
available to plan participants on the Monroe County website and will be accessible
24 hours per day. All presentations are less than 15 minutes. No pre-registration 2
will be required, but attendance will be tracked based on presentations viewed by
each individual. The online personal health assessment will provide participants
with a printed health assessment and the opportunity to voluntarily speak with a
health coach and request additional health support from the Florida Blue Next Steps .2
Programs. Minimum participation to be eligible for Health& Wellness prizes will
be the completion of the online health assessment and viewing the Employee
Assistance Program presentation. Wellness Funds will be used to purchase prizes
that promote healthy living (i.e., bicycles, fitness trackers, smoothie makers) for
participants who attend or participate virtually in annual Health & Wellness Fairs co
and complete their Passport to Wellness/virtual minimal requirements. For
possible in-person events,there will also be a cost for the use of the facilities where
the Health & Wellness Fairs will be held in the lower, middle and upper keys and 0
Wellness Funds will also be used for that purpose. The planned cumulative
expenditure for Wellness Funds used on the Annual Health & Wellness Fair shall
be fifteen thousand dollars ($15,000.00); but will be less if held virtually.
e. Due to the COVID-19 pandemic, the County suspended the services of Health
Designs, Inc., who provided Wellness Champion visits at various County and
Constitutional Offices and Facilities. This reduced the Wellness Program budget
expense by $45,000 annually. Due to the ongoing uncertainty of the COVID-19
pandemic, in lieu of restarting Health Designs, Inc. onsite services, staff will E
themselves research and deliver onsite or virtual Wellness Champion topics to plan
participants.
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C.2.a
Employee Participation in Wellness Events:
f. To the extent that business operation allows, employees will be allowed to
participate in Health & Wellness events, including but not limited to Annual
Employee Health & Wellness Fairs and Lunch & Learns that are held during 6
scheduled work hours without the use of vacation, sick or comp time. Employees
should attend during normal scheduled work time/hours. Employees voluntarily
choosing to attend prior to or after scheduled work hours is not compensable. .�
Health &Wellness Rewards:
g. Biometric Screenings: (Virtually or onsite, depending upon applicable future safety 0
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guidelines for COVID-19) Four hours of annual leave to Monroe County BOCC
employees and participating Constitutional Officer (Property Appraiser, Court
Administration, Land Authority and Clerk of Court) employees who participate in ,
the annual Health&Wellness Fair(minimum participation of biometrics and health
coach visit) or visit their personal physician and complete the online Personal
Health Assessment. Virtual requirements as noted in section D. Leave (above)will
be deposited the first payday in April, following the use-it or lose-it date each year. c
Florida Blue documents participation and provides confirmation data to employee
benefits for awarding of annual leave. Annual leave is distributed by employer and
is not funded by the Florida Blue annual contribution for wellness initiatives. t
Participation in the Monroe County Health& Wellness Program is voluntary.
h. Annual Wellness Exam and Age Appropriate Screenings: Participating employees
on the traditional Health Plan will receive $ 25.00 per month ($300 per year)
premium discount in 2022. Participating employees on the High Deductible Health
Plan with Health Savings Account(HDHP/HSA) will receive $300 deposited into
their Health Savings Account in 2022. This award is not funded by the Florida Blue
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annual contribution for wellness initiatives; but is reduction in revenue of the
internal service fund and is handled as a ledger entry. To be eligible for the discount
(BOCC and participating Constitutional Officer) employees must visit their
personal physician for an annual wellness exam and obtain the required age
appropriate preventive screenings, determined by staff and specified on the
Employee Health Preventive Care — Assessment Acknowledgement Form. In 0
program year ending October 31,2019;480 members completed the screenings and
received the reward.
i. Traditional Health Plan: Employees paying$50.00 per month for premiums ,
will be reduced to$25.00 and those paying$75.00 per month for premiums
will be reduced to $50.00 per month. These discounts are administered on
the employee direct deposit pay statements or pay checks.
ii. High Deductible Health Plan with Health Savings Account(HDHP/HSA):
Employees on this plan pay zero in premiums, so a monthly discount does
not apply. Instead employees on the HDHP/HSA will receive $300
deposited into their Health Savings Account. These funds are direct
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Packet Pg. 101
C.2.a
deposited into the employee's HSA each payday by their respective
participating employer/payroll.
Employees who attest to tobacco use are included in the ability to earn the employee
health insurance premium discount (Traditional Health Plan) or contribution to 6
HSA (High Deductible Health Plan with Health Savings Account). To be eligible
in addition to the age appropriate screenings required for all participants, those
attesting to tobacco use, must voluntarily participate and complete at least one
approved tobacco cessation program (programs vary in length) during the wellness
program period of the prior year (November 1, 2020 — October 31, 2021) and E
submit a certificate or letter of participation/completion from the facilitating
program. No-cost cessation programs are offered throughout Monroe County and
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South Florida by various organizations. Employee Benefits Staff will maintain and
regularly communicate a list of approved tobacco cessation program(s). Employees
inside or outside of Monroe County who are interested in another tobacco cessation
program not listed may submit the program name and contact information in
writing to the Benefits Administrator or Employee Services Director for eligibility
review. Employees must receive approval of other tobacco cessation programs in
advance in order for participation in those programs to qualify the employee for the 6
premium discount or HSA deposit. Monroe County's prescription plan provider 0
also supports tobacco cessation and covers tobacco cessation products (patches,
gum, Rx). Employees are not limited in the number of attempts to become tobacco
free during a calendar year. Participation in wellness and cessation programs are
completely voluntary. o
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Purchases of Goods:
i. Gato Building Gym: Up to $5000.00 annually shall be planned for equipment
maintenance, repair, and replenishment of fitness center supplies.
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Beginning November 1, 2019, the Gato Building Gym will be open to health plan
participants, spouses, and covered dependents age 18 and over. Since inception of 0
the gym, the facility was only available to health plan participants. This change o
increases the fitness opportunities for additional covered plan participants.
0
In 2017, county staff was authorized to spend up to Ninety-thousand dollars ($
90,000.00)in calendar year 2017 as part of the County's Wellness Program in order to v,
create a gym in the Gato Building(Gato Building Gym). The Gato Building Gym shall
be open to all employees and retirees in Monroe County Board of County ,
Commissioners ("BOCC"), Monroe County Land Authority, and the constitutional
officers (Property Appraiser, Supervisor of Elections, Clerk of court, Tax collector and
Sheriff) who are participants in the Monroe County health plan ("Employees and E
Retirees"). The County shall purchase and have ownership of the equipment. County
staff shall establish reasonable rules for use of the gym, including but not limited to
hours of operation, and may condition use of the gym on execution of documents by
the gym users waiving and releasing the County from any liability for the voluntary
activity. The Gato Fitness Center opened on May 14, 2018.
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C.2.a
Use of 2020 Wellness Funds among categories:
j. Employee Services may reassign funds among the wellness program categories 9
based on under or over utilization, in order to meet demand and manage the needs
of the specified programs. U-
2. Resolution No. 267-2019 is inconsistent with this resolution and is repealed on October 31,
2020.
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3. This resolution shall take effect on November 1, 2020. CL
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PASSED AND ADOPTED by the Board of County Commissioners of Monroe County,
Florida, at a regular meeting of said Board held on the day of 2020.
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Mayor Heather Carruthers _ C44
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Mayor Pro Tem Michelle Coldiron _ c
Commissioner Craig Cates
Commissioner David Rice _
Commissioner Sylvia Murphy eW�t
(SEAL) -
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ATTEST: BOARD OF COUNTY COMMISSIONERS
KEVIN MADOK, Clerk OF MONROE COUNTY,FLORIDA
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By: By: cV
Deputy Clerk Mayor �
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0
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C.2.b
County of Monroe VP
The Florida Keys
Employee Health Preventive Care-Assessment Acknowledgment Form
Passport to Wellness Year 2021
Services provided between: 11/1/2020 through 10/31/21
Discount Period: 1/1/2022-12/31/2022
Employee Name: Age: _
(Please Print)
Male: Female: EMPLOYER: (Please Print)
Physician Name: (Please Print) Completion Date:
Physician Acknowledgement: My signature below indicates that the following tests,assessments,clinicals indicated,pertain to CD
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the employee identified above,have been measured, if I deemed appropriate.The results of which have been reviewed with the
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employee in accordance with established treatment protocols. y
Biometrics Information:
Check if Recommended tests (Not required) if applicable at CN
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completed Physician's discretion:
Wellness checkup/Physical Comprehensive Metabolic Panel (CPT Codes 80053, 10
84436, 84479)
The below can be done at the County's annual Vitamin B
health fair or with your personal physician: 0.
Hei ht/Wei ht CBC <
Blood Pressure: Systolic/Diastolic CMP '✓
Cholesterol : LDL/HDL/Tri I cerides TSH
Blood Sugar Level Bilirubin screening
Body Mass Index BMI HBA1c if diagnosed diabetic
Required Preventive Screenings discussed with Physician. If screening is recommended and
done at a different office (such as a hospital), proof of procedure/visit with name of patient �-
and date of procedure must be attached to this form. CL
Mammogram: Annually at ages 40+
OR
Not required at this time (age, screening given within past year, etc.)
N
Pap Test/Pelvic Exam: Women age 21-65 every 3 years or women age 30-65 Pap Test/HPV combined every 5 year: N
Ages 65+discuss with doctor
OR
Not required at this time. _Date Last Completed:
Screening for Colorectal Cancer: Ages 50-75 with either a colonoscopy,fecal occult blood test or sigmoidoscopy
OR
Not required at this time Date Last Completed:
Pagel Of 2 Approved BOCC 2/21/18
Packet Pg. 104
C.2.b
Abdominal Aortic Aneurysm Check: One-time men ages 65-75 who have ever smoked or history of AAA
OR
Not required at this time
Lung Cancer Screening: Ages 55-80; 30 pack smoker history, current smoker/quit within past 15 years
OR
Not required at this time
Bone Mineral Density Screening and prescribed medication for osteoporosis: Women beginning 65+ and in
younger women who have increased risk
OR
Not required at this time
Prostate Cancer Screening: Discuss with doctor
Skin Cancer Screening: Discuss with doctor
HIV and other Sexually Transmitted Infections (STIs): Discuss with Doctor
Doctor:
I have given the patient the results of these tests and the employee has been counseled on the results and CL
necessary follow up to prevent further health issues: y
Physician Signature: Date:
Physician Address:
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Physician Phone #: o
Please give patient a copy of this form,completed by physician and mail completed,signed form to: Monroe
County Employee Benefits Office
Gato Building,2nd Floor, Room 268
1100 Simonton Street
Key West,FL 33040
EMPLOYEE SIGN BELOW:
I hereby certify that I do not currently use tobacco products and agree to remain tobacco free while participating
in the Wellness Program. Tobacco products are defined as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip, CL
electronic or e-cigarettes that contain nicotine or any other product that contains tobacco or nicotine. Nicotine
replacement products such as gum and patches are also considered tobacco products. I further understand that I may LU
be subject to testing to verify non-use of tobacco products. A refusal to submit to a test is considered "positive" for
tobacco use. LU
I hereby certify that I currently use tobacco products, and have completed a qualified tobacco cessation
program during the wellness program period and have attached a copy of documentation verifying my participation
(certificate/letter). Tobacco products are defined as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip,
electronic or e-cigarettes that contain nicotine or any other product that contains tobacco or nicotine. m
NOTE: *Original assessment form completed by physician must be submitted to Monroe County Employee Benefits Office along
with any proofs of age appropriate screenings. DO NOT email or fax.
*If COVID-19 safety measures are recommended,clear and legible email/fax submissions as above will be accepted.
Employee Name Employee Signature Date
Submitted to County on:
Date
Received by Employee Services Employee Name/Signature: Date:
Page 2 of 2 Approved BOCC 2/21/18
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