LETTER TO PARTICIPANT. Civilian Employee Wellness Program Participant Marine Corps Community Service Base Henderson Hall

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1 Dear Participant, MARINE CORPS COMMUNITY SERVICES HENDERSON HALL HEADQUARTERS & SERVICE BATTALION, HEADQUARTERS MARINE CORPS, HENDERSON HALL P.O. BOX 4009, ARLINGTON, VIRGINIA LETTER TO PARTICIPANT Civilian Employee Wellness Program Participant Marine Corps Community Service Base Henderson Hall Thank you for your interest in the Marine Corps Community Services Base Henderson Hall Civilian Employee Wellness Program. Studies show that improved health overall improves morale, productivity at work and home, and less illness. These next six months will be a learning process in order to help you understand the benefits of a healthier lifestyle. With the onset of the importance of preventative health care this past decade, the Wellness Committee is committed to helping you achieve your goals so you can reap the benefits of a healthy lifestyle. Upon approval from your supervisor, you will be permitted to utilize the gym, group exercise classes, or exercise on base, no more than three 59 minute sessions per week, during the next six months. The time allowed will be three hours of government time. The use of these hours for anything other than attending classes or utilizing the base gym or pools for exercise will not be permitted. During the next six months, you will improve your health and quality of life by participating in a program that accommodates your needs. In addition to time permitted, MCCS offers various opportunities to attend Health education/training presentations/courses throughout the year regarding the latest information on nutrition, stress management, health management, cardiovascular disease risks, weight management, smoking education and cessation, and physical activity. Therefore, no matter what your current fitness level and health status may be, anytime is a good time to start. Therefore, for most people, starting a very basic program is safe. However, sometimes a medical clearance is necessary. Thus, if you are a man over age 40, a woman over age 50, have not exercised on a regular basis (within six months), or answer yes to any of the questions on the Physician s Referral Form, you will have to provide your doctor s approval before making a consultation appointment at the Semper Fit Division, Building 27 Smith Gym. Otherwise, complete this packet and make an initial appointment via at derek.soloway@usmc.mil or call To your health, Derek P. Soloway; LAT, ATC, PES Semper Fit Enclosure (1)

2 I understand that a trained specialist will supervise, directly or indirectly, the MCCS Henderson Hall Civilian Employee Wellness Program in which I will participate. There may be some slight risk associated with the exercise program. There is a chance that some cardiovascular problem could develop and, in a very rare instance, a heart attack could occur. Excessive exercise in hot, humid conditions can lead to heat injury such as heat exhaustion or heat stroke. This danger can be reduced by altering my exercise program during hot, humid weather; by drinking plenty of water; and by recognizing the early signs of heat injury. Careful medical screening prior to entering the program minimizes these risks. If further diagnostic of therapeutic care is needed, I understand that it is my financial responsibility. There are numerous benefits to participating in the MCCS Henderson Hall Civilian Employee Wellness Program. I will learn how to improve my diet, lose weight, manage stress, and how to exercise safely and effectively through attending classes and exercising during specified hours during the weeks on my program. Improving these health practices is thought to improve my overall health status and functional ability. I have had the chance to have my questions answered to my satisfaction about this program. I understand that if I have additional questions, I may contact Derek Soloway; LAT, ATC, PES, Semper Fit Division, at Signature Date Witness Signature Date Enclosure (2) Enclosure (2) 2

3 List of Approved Activities For purposes of coverage under the Civilian Employee Wellness Program (CEWP) only recognizes the physical fitness activities listed below as approved aerobic activities: Approved activities are those that address one or more of the following three areas of fitness: (1) aerobic/cardiovascular endurance (2) strength training (3) flexibility The following activities are authorized as aerobic activities for CEWP: a) Brisk walking b) Jogging c) Running d) Cycling e) Stair climbing f) Rowing g) Swimming h) Rope-skipping (Jumping Rope) i) Skating j) Aerobic exercises (such as aerobic classes, calisthenics, etc.) k) Strength/resistance exercises (such as weight training, including the use of free weights, calisthenics, etc.) l) Flexibility exercises (such as stretching, yoga, etc.) Activities not listed above are not part of this program, and are not covered by the CEWP Enclosure (3) 3

4 HEALTH HISTORY QUESTIONNAIRE NAME: DATE: WORK PHONE: SEX: M F AGE: PERSON TO CONTACT IN CASE OF EMERGENCY: NAME: RELATIONSHIP: PHONE: ALTERNATE PHONE: ARE YOU TAKING ANY MEDICATIONS OR DRUGS? IF SO, PLEASE LIST MEDICATION, DOSE, AND REASON. DOES YOUR PHYSICIAN KNOW YOU ARE PARTICIPATING IN THIS PHYSICAL FITNESS PROGRAM? DESCRIBE ANY PHYSICAL ACTIVITY YOU DO SOMEWHAT REGULARLY: DO YOU HAVE OR HAVE YOU HAD IN THE PAST: YES NO 1. History of heart problem, chest pain stroke 2. Increased blood pressure 3. Any chronic illness or condition 4. Difficulty with physical exercise 5. Advice from physician not to exercise 6. Recent surgery (last 12 months) 7. Pregnancy (now or within the last 3 months) 8. History of breathing or lung problems 9. Muscle, joint and back disorder or previous injury still effecting you 10. Diabetes or thyroid condition 11. Cigarette smoking habit 12. Obesity (more than 20% over ideal weight) 13. Increased blood cholesterol 14. History of heart problems in immediate family 15. Hernia or any condition that may be aggravated by lifting weights Please explain any yes answers. COMMENTS: DO YOU HAVE ANY OTHER CONCERNS YOU DESIRE TO EXPRESS PRIOR TO ENGAGING IN THIS PHYSICAL FITNESS PROGRAM? YES NO IF YES, PLEASE EXPLAIN: SIGNATURE: REVIEWED BY: DATE: DATE: Enclosure (4) 4

5 PHYSICIAN S REFERRAL FORM Dear Dr., Date: Your patient,, desires to participate in a physical fitness program at the gym located at his/her workplace with a health and fitness professional. Our initial medical screening identified the following potential risk factors: Age - 40 years or more (males); 50 years or more (females) Smoking Diabetes BMI measurement of indicates minimal, low, moderate, high, very high, extremely high disease risk factor Family history of cardiovascular disease in parent or siblings prior to age 55 Symptoms or signs suggestive to cardiopulmonary disease Has not been recently (within six months) involved in a regular moderate exercise program Other Because of these factors, our guidelines require your patient to obtain a clearance from you prior to participation in a physical fitness program. This program is voluntary on the part of your patient because he/she is concerned about his/her health and would like to participate in a program that would better his/her overall health. Please complete the attached Physician s Approval Form and return it to the Semper Fit Division either by your patient or by mail, or by fax to (703) If you have any questions, please contact Derek Soloway; LAT, ATC, PES with Semper Fit Division at (703) Enclosure (5) 5

6 PHYSICIAN S APPROVAL FORM Return to the Semper Fit Division either by the patient or by mail to: Fitness Specialist Attn: Derek Soloway; LAT, ATC, PES Marine Corps Community Services Semper Fit H&S Bn, HQMC Henderson Hall PO Box 4009 Arlington, VA Or fax to: (703) has medical approval to (Print patient s name) participate in a physical fitness program at the MCCS Henderson Hall in Smith Gym. I understand that the program includes mild to moderate intensity exercise, is conducted individually or in a group, and is either supervised or unsupervised. I also understand that participation is voluntary, allowing the participant to stop and rest at any time he/she desires. The following restrictions apply (if none, so state): Physician s Name: Physician s Signature: Telephone: Date: Enclosure (6) 6

7 HEALTH AND FITNESS PHILOSOPHY AND GOAL SHEET Please write a statement on how you believe you will benefit from enrolling in the MCCS Henderson Hall Civilian Wellness Program. Please list the immediate, intermediate, and long-term goals in relation to your health and fitness. Immediate: Intermediate: Long-Term: EMPLOYEE SIGNATURE: DATE: Enclosure (7) 7

8 MEMORANDUM OF UNDERSTANDING FOR PARTICIPANT I,, understand that my full participation in the MCCS Henderson Hall Civilian Wellness Program will require three onehour sessions each week for a total of 72 hours over the course of six months, unless illness or injury dictate otherwise. I understand that participation will be my place of duty if permitted to attend during working hours. I hereby agree to hold harmless and release the United States Marine Corps and the United States Navy of all claims and demands resulting from any loss, damage, death, or injury to me or my property that may arise due to my participation in this program other than negligence on my behalf. I understand that some portions of this program may be physically demanding and I certify that I am in sufficient health to participate in the MCCS Henderson Hall Civilian Employee Wellness Program. I have read and understand the requirements of the participant guidelines. Employee s Signature: Date: Enclosure (8) 8

9 MEMORANDUM OF UNDERSTANDING FOR PARTICIPANT AND SUPERVISOR Name of Employee: Directorate/Program Number: Name of Supervisor: Bldg #: Job Title: Work Phone Number: Fax Number: Address: I,, the supervisor of the individual stated above, understand that he/she will be participating in the MCCS Henderson Hall Civilian Employee Wellness Program for three one-hour sessions each week for a total of 72 hours over the course of six months. I understand that participation will be the place of duty for the above-mentioned individual and that I agree to allow my employee to attend during working hours beginning and ending. I also understand that the exercise periods are official duty time. Failure to use exercise time appropriately or misconduct during these periods will be considered workplace infractions and will be subject to disciplinary action. I also am aware that unused exercise hours of the participant may not be carried forward to subsequent weeks nor can they be used for any non-duty purpose. Employee/Participant: Date: Participant Approve/Disapprove: Date: Supervisor Approve/Disapprove: Date: Director Enclosure (9) 9

10 Civilian Employee Wellness Program Record Sheet Employee Division DATE TIME START TIME END LOCATION & ACTIVITY Employee Signature: Date: Supervisor Signature: Date: Enclosure (10) 10