Staff Guide Dover

2011Onsite Screenings

Section Dover Overview Dover Branding StayWell Overview Company Profile Program Overview Personal Health Screening Details Personal Health Assessment Lifestyle Management Coaching Eligibility and Incentives Policies and Procedures Dress and Appearance Professionalism Equipment Quality Control Handling/Return of PHI Emergency Referrals Onsite Incidents and Contact Information Onsite Details Materials and Supplies Roles and Responsibilities Registration Screening Measurements Health Education Important Reminders Quiz 26 Appendix Dover Consent Form ERF 30 PHA Info Sheet Evaluation Health Education Script Hipaa Form Pre Screning Check List Post Screening Check List Summary Slip

Page 3 4 5 6 7-11 8 9 10 11 12-17 12 13 14 15 16 17 18-24 18 19 20 21-23 24 25

27 28

31 33 34-36 37 38 39 40

Dover Overview (Keep this page with you at the screening to be used as a quick reference as needed) Total Rewards

Program Name:

Screening Population:

Manufacturing, white collar, administrative, engineers

Screening Values:

Height/Weight Waist Circumference BMI Blood Pressure Total Cholesterol

HDL Glucose 3-5 minute Health Education

Other programs being promoted at screening:

Personal Health Assessment

Health Assessment (HA):

Online or paper completion Available 1/1/2011-3/31/2011 for the incentive. The HA will remain open for new hires through the end of the year.

Screening/ Health Assessment Eligibility:

Screening: Employees and spouses covered under the Dover medical plan. Participants not covered by the Dover medical plan may be eligible this varies by site, refer to the site information sheet for details Health Assessment: Must be enrolled in the Dover medical plan $100 gift card for completion of Personal Health Screening OR Health Care Provider Form (to receive the incentive the participant must have all values documented) AND completion of the Personal Health Assessment. Only Dover benefits enrolled participants will be eligible for this incentive.

Screening/HA Incentive

Individual locations/op-cos may have additional incentives. Please refer participants to HR if they have questions about additional incentives 1-800-947-9560 option 3

Program Phone:

Program Website:

https://dover.online.staywell.com

Materials participant should walk away with:

Pink copy of consent Pink copy of Emergency Referral Form (if applicable) HA information sheet (two sided) Fast Guides

Plan for returning PHI:

Lead to bring PHI to a staffed UPS store and send back to StayWell using next day air ship labels

Other Special Requirements/ Additional Information:

Ensure that the entire Consent Form has been completed Ask participant to complete a Satisfaction Survey and leave in separate area Ship PHI from a staffed UPS location This is the first time that the op-cos are coming together for their wellness program under the Dover umbrella. Locations may have slight variations to their programs. Be prepared to be flexible and refer participants to HR for details On the consent form the full SSN is requested. Inform the participant that they only need to fill in the last 4 digits Location/op-co specific details will be listed on the SIS. Its extremely important that you review your site information sheet in advance so youre prepared to accommodate site specific programs.

Dover Branding Below is a list of some of StayWells products and services. Dover has assigned new branding to each of these products and services. Please use the Dover branding when working with participants. StayWell Product/Service Health Assessment Health Screening NextSteps StayWell Helpline StayWell Online Wellness Program All of StayWells services Incentive Eligible population Dover Branding Personal Health Assessment Personal Health Screening Lifestyle Management Coaching Dover Health Support Services Line Dover Health Support Services Online Health Portal Dover Total Rewards Benefits Program Dover Health Support Services Wellness Reward Dover Medical Plan Covered Employees and Spouses

StayWell Overview
StayWell Health Management delivers comprehensive health management programs and services that help organizations maximize business results by improving employee health and productivity. StayWell Health Management has focused on corporate health management since 1978 and leads the industry with the longest history, broadest base of experience, and best track record in employee health management. StayWell designs and manages programs for employers throughout the United States, offering such services as screenings, health assessments, online programs and wellness campaigns. Dover, StayWell and WorkSite Health Dover has partnered with StayWell to provide their employees our health management programs. Health screenings are one of the many services StayWell will be providing Dover. StayWell has partnered with WorkSite Health to provide quality screening services to Dover participants. WorkSite Health will represent StayWell at the onsite screenings. If asked who you work for when onsite, please state that you are providing services on behalf of StayWell Health Management.

Notes

Company Profile
Dover Corporation is a multi-billion dollar, global producer of innovative equipment, specialty systems and value-added services for the industrial products, fluid management, engineered systems and electronic technology markets. Dover Corporation is a decentralized corporation that supports autonomous operating companies focused on meeting the demands of their customers and served markets. Dover is made up of 40 individual businesses. These businesses are referred to as Operating Companies (Op-Cos). The name of the Op-Co will be included on the SIS. Employees identify with their Op-Co as their place of employment rather than Dover. Dovers population is made up of a very diverse group. Their population includes people in manufacturing, administration, engineering, and management.

Dover has given the individual Op-Cos a certain amount of flexibility with their Personal Health Screenings. The basic screening format will be the same for all locations. However, additional incentive designs, eligibility, and presence of a health fair will vary from site to site. This information will be included on the site information sheet. The training materials are set up to guide you through a standard Dover screening. Any deviation from this guide will be documented in the SIS. Several of Dovers contracted vendors, including StayWell and Magellan, will be onsite at some of the screening locations. Their primary role is to observe the event and to speak with the site coordinator; however the StayWell staff will be prepared to assist with registration and flow as needed. Magellan is Dovers Employee Assistance Program (EAP) vendor. They will be distributing brochures and providing information to employees. If any additional vendors are present they will be promoting their programs similar to a health fair setting.

Notes

Program Overview
Dover Total Rewards
Several programs are offered to Dover medical plan enrolled employees through the Dover Total Rewards program provided by Dover. As part of Dover Total Rewards, Dover medical plan enrolled employees receive such benefits as:

Free onsite health screenings provided by StayWell The opportunity to complete a free, confidential Health Assessment provided by StayWell The opportunity to participate in StayWells NextSteps programs

Notes

Program Overview (contd)

Personal Health Screening Details
Dover refers to the screening as a Personal Health Screening. This is the 1st year Dover will be offering screenings to its benefits enrolled employees through StayWell. Benefits enrolled employees have been given the option to attend the screening at their worksite or submit a Health Care Provider Form (HCPF).

Dover is holding screenings at 67 locations this year. Screenings will be held from 1/17/2011-3/11/2011. Hours of the screenings vary by site. The flow rate of the events varies from 4 -24 participants per hour. StayWell and Dover will be managing schedules for these events using the online scheduling tool and paper templates. Site coordinators will share with staff the schedule of appointments prior the start of each event.

Benefits enrolled employees who cannot attend an onsite screening will have the opportunity to complete a Health Care Provider Form and submit it to StayWell. Health Care Provider Forms will be available via StayWell Online Site or Human Resources.

Screening Flow Screenings will include measurements of height, weight, waist circumference, blood pressure, total cholesterol, HDL, and glucose. Following the measurements portion of the screening, participants will receive a 3-5 minute review of their biometrics with a health professional. The participant must obtain values from all stations to be eligible for the incentive. As always, it is important that you provide every participant with a high-quality screening experience, but it is equally important that you manage the flow of the event to minimize the time commitment of the screenings and ensure they do not interfere with work schedules and responsibilities. Dovers Role Dover will provide site coordinators for each location. These staff are responsible for preparing their location for the screening event, but are not required to be present at the screening. Site coordinators will greet you at the designated entrance one hour prior to the start of the event. Notes

Program Overview (contd)

Personal Health Assessment (PHA) Details
Dover refers to the HA as a Personal Health Assessment (PHA). The Personal Health Assessment is a confidential, personalized health questionnaire designed to provide information, resources and motivation to improve health and well-being. It is important that you, as a StayWell representative, knowledgeably speak to the PHA and encourage participation. Benefits enrolled employees will have the option to complete the online PHA or request a paper version of the StayWell PHA through their local human resources office. The individual Op-Cos will be billed for the paper PHAs. It is up to each Op-Co to determine if they want to pay for paper PHAs. Encourage pariticipants to complete the online PHA over the paper version, Benefits enrolled employees should be instructed to complete the PHA following their screening appointment. Health Educators should provide the participants with an overview of the following:

The PHA is currently open. Participants can access the PHA online at the link listed on the bottom of the consent form (this link is also on the PHA information sheet) Screening values will be loaded into the participants PHA approximately 2-3 weeks after the screening Benefits enrolled employees must complete the online PHA by 3/31/2011 to be eligible for the PHA/Personal Health Screening (PHS) incentive. Paper HAs must be received by mail at StayWell by 3/15/2011 to be eligible for the HA incentive PHA Sheets with login instructions will be distributed to each participant at the screening. For Dover this is a one page document with text and pictures on both sides

Notes

Program Overview (contd)

NextSteps (Dover refers to NextSteps as Lifestyle Management Coaching)
Upon completion of the HA, participants will receive an invite into StayWells NextSteps (phone, mail) or Healthy Living Programs (online). These are behavior-based programs offered to the employee free of charge. If the participant completed the online HA, they will receive an instant invite to enroll in a NextSteps program immediately. If the participant completed a paper HA, the participant will receive an invite into NextSteps when StayWell has received the paper HA by mail. Health educators should promote the NextSteps programs and encourage all participants to enroll in a NextSteps program when they complete their HA, especially those participants who have elevated values and/or a lot of questions at the screening. As a StayWell representative, we expect that you can knowledgeably speak to the NextSteps programs. The three modes of participation are described below: Phone-based Next Steps The phone-based health coaching program is personalized and tailored to fit the participants unique individual needs. Participants work 1-on-1 with a Health Coach in a series of phone calls to set goals, determine readiness to change, discuss barriers and strategies and document progress toward goals. The health coaching program is the most effective of the NextSteps programs. Mail-based Next Steps Participants receive monthly mailings for a six-month period. Mailings include personalized letters, educational brochures and booklets to help them set goals, identify barriers, build skills for overcoming barriers, make progress on new behaviors, strategize self-rewards, and stay motivated. Online Healthy Living Program Participants move at their own pace if they enroll in an online program. They will have access to numerous tools and resources on StayWell online.

Notes

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Program Overview (continued)

Personal Health Screening, Personal Health Assessment, and NextSteps Eligibility
Benefits enrolled employees and benefits enrolled spouses are eligible to participate in the Personal Health Screening, PHA for the incentive. There is no incentive for the NextSteps programs. *Note: Each individual OpCo will be billed directly for any participant not enrolled in benefits (refer to your SIS for eligibility details as they vary by site). It is important that you confirm eligibility prior to completing any measurements. Discuss with the site coordinator how best to handle anyone in question prior to the start of the screening.

Incentives
Those who qualify to receive the incentive are benefits enrolled employees and benefits enrolled spouses. The incentive will be a $100 gift card for completion of the Personal Health Screening OR Health Care Provider Form (the individual must participate in all stations and have all values documented to be eligible for the incentive) AND completion of the Personal Health Assessment. Incentives will be distributed at each Op-Co through human resources. All gift cards will be issued in the employees name. Please refer incentive-related questions for the $100 gift card to the StayWell HelpLine and any local incentive questions to local HR.

StayWell HelpLine (Dover Health Support Services Line)

Participant questions and/or concerns regarding StayWell programs can be directed to the StayWell HelpLine at 1-800-947-9560 option 3.

Notes

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Policies and Procedures

As a representative of StayWell at onsite screenings, it is expected that all screening staff present themselves in a professional, healthful manner both in action and appearance. It is important to the success of the program that all policies and procedures are adhered to.

Dress and Appearance

All staff and clothing is to be free of offensive odors (such as the smell of smoke, heavy fragrances, lotions, etc.). Some products may have a potentially negative effect on persons sensitive to fragrances You are providing a health service, and may be asked to leave if you smell of tobacco smoke

All staff must wear black pants, a plain white button up shirt with a StayWell nametag and black closed toe shoes. Variations in this policy are prohibited (i.e. shirts with designs, ruffles or high waist belts and/or jeans, skirts or capris rather than pants).

Notes

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Policies and Procedures (continued)

Professionalism

Conversations should be appropriate and not include profanity. Conversations should be kept to a minimum to avoid disclosing inappropriate information to participants or site contacts. If a site contact asks you information unrelated to the screenings, please redirect the conversation. Examples of inappropriate conversation may include: how you found the position, screening experience, personal views, unhealthy food cravings, going out, etc. If a participant or site contact asks you about your experience, simply inform them of the license/degree you hold.

Do not endorse programs for which the participant is not eligible. Examples of endorsements may include promoting a campaign or other StayWell program that the client has not purchased or promoting an organization that youre affiliated with (i.e. holistic health, a specific fitness center, etc.). Keep in mind that some Op-Cos may allow participants who are not enrolled in the benefits through the screening. These people are NOT eligible for the PHA. StayWell will provide you information regarding all of the resources/programs available to participants prior to the screenings. Electronic Devices (i.e. cell phones, laptops, PDAs) should not be used on the screening floor. If a call needs to be made, please notify the lead staff and leave the screening area. Calls should not disrupt the flow of the event and should only be taken in an emergency. Magazines, books, doodling etc. should not be present in the screening area. No food or drink shall be allowed at screening stations, with the exception of water. Breaks should be taken as necessary or as determined by the screening schedule. If there are no scheduled breaks, you must rotate in a qualified staff person, which does not include StayWell staff or site coordinators.

Notes

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Policies and Procedures (continued)

Equipment Quality Control
Equipment must be tested prior to use onsite.

Run optics checks on each Cholestech machine to be used prior to the start of the screening. Log results of optics checks in your equipment control log

Lead staff should measure their height on the stadiometer prior to the screening start to ensure accuracy. Log results on the pre-screening checklist

Lead staff should weight themselves on the scale prior to the screening start to ensure accuracy. Log results on the pre-screening checklist

Lead staff should test their blood pressure on all cuffs to be used prior to the screening start to ensure accuracy. Log results on the pre-screening checklist

Standard vendor policy must be followed if any control checks reveal defective equipment (i.e. take the machine out of service, replace/fix equipment, etc.) Notify StayWell immediately if the situation cannot be remedied

Notes

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Policies and Procedures (continued)

Handling/Return of Personal Health Information (PHI)

Do not allow site coordinators or any other employees to handle PHI. They should not be making copies of any documents containing PHI including Emergency Referral Forms. Consent Forms, Emergency Referral Forms and any other paperwork containing PHI should always be placed face down on tables. PHI should never be left unattended. It is the lead staffs responsibility to ensure that all PHI is accounted for and secure. The lead should carry all PHI with them when on break or at the end of the screening day. Values must never be said out loud. Instead, point to the values on the Consent Form. StayWell staff will be onsite at several of the events. Please follow standard shipping procedure unless the StayWell staff identifies themselves as a St. Paul-based employee and is able to carry the PHI back to StayWell. Screening staff must follow the instructions outlined in the return shipment packet sent with the materials and supplies to return PHI to StayWell: Follow the step-by-step instructions on the Post-screening Checklist to properly return materials to StayWell. Please place any no reaction or refusal consent forms on the bottom of the PHI stack when possible. Complete the Screening Summary Slip. Seal all PHI in the provided envelope and affix the provided return label to the envelope. If more than one envelop is required, please place the envelopes in a box to ship back to StayWell whenever possible. If no box is available, label envelopes with location and package number (i.e. package 1 of 2). Affix a return label to each envelop and label the envelopes with Confidential to StayWell. The lead screening staff must bring the PHI to a staffed UPS drop location to be sent back to StayWell within 48 hours of the screening, documenting tracking numbers, date, time and location and shipment. Dover has a limited budget for shipping expenses. Please combine PHI into 1 box rather than shipping several small envelopes and avoid shipping on weekends whenever possible to help keep shipping costs to a minimum. Compose an email summary of the days event and send to Cal.

Notes

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Policies and Procedures (continued)

Emergency Referral Forms
An Emergency Referral Form must be completed for any participant that has an elevated blood pressure or glucose based on the recommendations on the form. The participant can either accept or refuse the recommendation provided to them and must sign the form. Give the participant the pink copy. (Keep this with the Consent Form to be sure the health educator sees it). Check the critical values discussed box on the Consent Form.

For blood pressure: record 3 readings on the Consent Form prior to starting an Emergency Referral Form. If the values drop significantly by the third reading (below 140/90), completion of a form is not necessary. The third reading must be taken manually. Wait 3-5 minutes prior to taking the final blood pressure reading.

All glucose measurements <50mg/dL or >300mg/dL, need to be documented on the Emergency Referral Form. Please refer to the form for specific recommendations.

Notes

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Policies and Procedures (continued)

Onsite Incidents
Any onsite issues, including HIPAA violations, participant concerns, staffing issues and emergencies must be communicated to StayWell as soon as possible. It is the lead staffs responsibility to contact Cal or StayWell directly to report any issues. Mitigation Plan for HIPAA Violations Any unintended disclosures of PHI must be reported to StayWell immediately, and written documentation must be reported within 3 days of the occurrence (refer to the HIPAA Violation Incident Report in the Forms attachment). Emergency Procedures It is the lead staffs responsibility to discuss the sites emergency action plan with the site coordinator prior to the start of the event and to ensure that all staff has a clear understanding of the plan prior to the start of the screening. If there is an emergency on site, the lead staff should always stay with the participant. An additional staff should be sent to contact the site coordinator to be sure we follow the appropriate emergency action plan for that location. Maintain as much privacy as possible. *Always call 911 immediately if you are in doubt StayWell Contacts Questions or concerns can be directed to: Katie Storlie Katie Kamrowski Jodi Annis Jessica Carlson 651-681-3318 (work) 651-365-7195 (work) 651-365-7143 (work) 651-681-3315 (work) 612-741-1973 (cell) 507-450-8806 (cell) 920-217-3859 (cell)

Notes

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Onsite Details
Materials and Supplies
Provided by StayWell

Provided by Vendor

Consent Forms Emergency Referral Forms Participant Satisfaction Surveys

Stadiometer Scale BP cuffs (automatic with manual backups of various sizes) Privacy Screens Cholestech machines and fingerstick supplies

FastGuides Health Assessment Sheets BMI charts Pens Shipping supplies

Please refer to your Site Information Sheet for specific instructions regarding leftover material. Unless otherwise instructed on your Site Information Sheet, all additional leftover materials should be left onsite for recycling. Leftover brochures should be given to the site coordinator for employee use.

Provided by site coordinator prior to the start of the screening:

Hard copy of the schedule Box to collect participant satisfaction surveys

Notes

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Onsite Details
Roles and Responsibilities
As the screening vendor, you are responsible for the following tasks:

Room set-up/re-arrangement. Ensure that all equipment has been calibrated and is working properly at all times. Managing the registration table. Complete measurements for height, weight, waist, blood pressure and fingerstick. Record values on the Consent Form. Complete emergency referrals as necessary. Monitor event flow. Health education. Manage completion of satisfaction surveys. Monitor PHI (Consents, ERFs, etc.) to ensure confidentiality. Be available to answer participant questions. Ship PHI at the end of the screening event.

Notes

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Onsite Details (continued)

Registration
It is WSHs responsibility to manage registration at the event. Responsibilities of the registration staff include:

Obtain the schedule of appointments from the site coordinator prior to the event start. Greet participants and welcome them to the health screening. All scheduled appointments take priority. Walk-in appointments should be scheduled during openings on the schedule. If the schedule is full, explain that it may take longer for them to get through the process as those scheduled must take priority.

Check participants in on the schedule. At most of the location/Op-Cos, participants have been asked to bring their Dover benefits card with them to the screening as proof of their eligibility for the screening. The site information sheet will have specific details for the process of checking participants in. Please refer to the SIS for direction. You can also work with the site coordinator to determine a participants eligibility. This process is extremely important as the individual Op-Cos will be billed for any participant who is not enrolled in the Dover benefits plan. We expect that staff will discuss the appropriate process with the site coordinator prior to the event start to avoid any delays during the screening.

Instruct participants on how to complete the Consent Form. The consent form requests the full social security number, however participants should be instructed to only provide the last four digits of their SSN,

Direct participants to the first screening station. Advise participants to remove shoes and other items that may contribute to weight.

Notes

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Onsite Details (continued)

Screening Measurements
Measurements include height, weight, waist circumference, blood pressure, total cholesterol, HDL, and glucose. The participant must participate in all stations and have values documented on the consent form to be eligible for the screening. Be sure to document refused on the consent form if the participant refuses a station and no reaction if the participants blood work does not process so we can clearly define who is eligible for the incentive. Follow the below standards when performing all components of the screening. Height

Measured with shoes off, hats off and any additional items set aside (purses, cell phones etc.). Use of stadiometer required. Record height on the Consent Form in feet and inches and in inches (i.e. 65, 77 inches). Participants will not be allowed to self report height. Clearly document on the consent form if the participant refused this measurement.

Notes

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Onsite Details (continued)

Weight

Measured with shoes off and heavy items removed from pockets. Any individual who appears to weigh more than 300lbs should be asked to self report their weight to eliminate the chance of causing an embarrassing situation if the scale only reads up to 300lbs. Participants will not be allowed to self report weight unless their weight exceeds the weighing capability of the scale. Clearly document on the consent form if the participant refused this measurement.

Waist Circumference

If the participant has a girdle or restrictive device on, they must take it off prior to being measured. Ensure that the measurement is taken on the skin at the level of the belly button. If the participant does not have a belly button or the measurement is obscured, then take the measurement at the midpoint between the top of the hip bone and the bottom of the rib cage.

Ensure the tape is snug, but does not compress the skin. It should be parallel to the floor and not over any clothing. Read the measurement at the end of a normal expiration of breath. Do not ask the participant to blow out all their air or hold in their stomach. Please ensure privacy at all times when doing the waist measurement. Participants will not be allowed to self-report their waist circumference. Clearly document on the consent form if the participant refused this measurement.

Notes

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Onsite Details (continued)

Blood Pressure (BP)

Use an arm cuff (automatic or manual). Be sure the participant is sitting with feet flat on the floor and staying silent while BP is measured. Measure BP on skin whenever possible (rather than rolling up a sleeve that bunches or taking measurement over long sleeves). Ensure that the cuff is properly placed on the arm. Take two automatic and one manual blood pressure reading for any participant whose blood pressure is over 140/90. Allow the participant to sit quietly for 3-5 minutes prior to taking the 3 reading. If by the third reading the participants blood pressure does not drop below 140/90, complete an Emergency Referral Form (refer to policies and procedures on page 12 for further detail).
rd

If a participant requests to have their BP retaken even if it is not clinically elevated, give them that option, but communicate that if there are others in line they may have to wait a few minutes so as to keep the event flow moving appropriately. Participants will not be allowed to self-report their blood pressure. Clearly document on the consent form if the participant refused this measurement.

Fingerstick

Record total cholesterol, HDL, and glucose on the Consent Form. Be sure to select fasting status on the bottom of the Consent Form. Fasting: no food/drink except water, black coffee or sugarless gum for 8 hours or more Non-fasting: food/drink/gum within 8 hours of the screening

Complete an Emergency Referral Form for all participants with glucose <50 or >300. Check the Critical Values Discussed box on the Consent. Detach the white and yellow copies of the completed Consent Form and place in a downward facing stack near you, but away from participants. o Please do your best to keep forms with refusal or no reaction separated from the stack so that they can be easily identified at StayWell.

Place the pink copy of the Consent Form facedown on a separate stack. Health Educators will coach off of the pink copy of the form.

Notes

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Health Education
Health education will be a 3-5 minute review of biometric values at a separate station. Refer to the Health Education Script in the appendix for additional detail.

Call the participants first name and ask them to state their last name. Privately verify one other unique identifier on the Consent Form (date of birth, phone number, etc.) prior to consultation. Review the screening results with the participant. Explain what each value is, the desirable range, and how this relates to the Provide suggestions and encouragement; use the health education script as a guide. Provide 1-2 FastGuides based on risk areas and refer participants to the back of their Consent Form for additional information.

Provide the participant with a PHA Sheet and encourage completion of the HA and participation in NextSteps. Provide the participant with the pink copy of their results for their own personal record. Instruct the participant to complete a satisfaction survey and thank them for attending. For any location/op-co specific requests, please refer to the SIS.

Notes

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Important Reminders

All participants must have completed and signed a Consent Form before any screening measurements are taken. If participants do not wish to share the last four digits of the SSN, they can omit this section but must be sure to fill out their full name, date of birth and gender. Be sure that values are not being stated out loud. Always write the value on the Consent Form and point to it. Give a brief explanation on what you will be doing at each station. Do not leave any PHI out on tables during breaks. Always keep any Consent Forms and Emergency Referral Forms face down. Ship all PHI back to StayWell according to the instructions provided in the shipment packet and on your Site Information Sheet. Please refer to the site information sheet for op-co/location specific details prior to the event start. Notify StayWell immediately if you are unsure of the process for a specific event. Be sure to document refused on the consent form if the participant refuses a station and no reaction if the participants blood work does not process. The participant must participate in all stations and have values documented on the consent form to be eligible for the incentive. On the consent form the full SSN is requested. Inform the participant that they only need to fill in the last 4 digits

Notes

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Quiz
1) What are the three requirements to receive the $100 gift card? 2) What is the name of the Dover wellness program? 3) How does Dover refer to the health assessment, health screening, and StayWell HelpLine? 4) Where should you look to find specific details for a particular location/op-co? 5) Does a participant need to provide their full SSN on the consent form? 6) T or F-I need to document no reaction if a participants blood sample does not process. 7) What step must be completed prior to screening a participant?

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Appendix

2009 StayWell Health Management | Dover Staff Training

27

PARTICIPANT CONSENT FORM

Last Name:

First Name:

Home Phone:

SSN :

-- --
Male: Female: Date of Birth:
(MM) (DD) (YYYY)

Voluntary Participation. I want to participate in the biometric screening offered by Dover Corporation and its related subsidiaries and affiliates (Dover) through StayWell Health Management (StayWell) and their respective agents and employees. Blood Test. I want to know my total cholesterol, HDL cholesterol and glucose levels and authorize StayWell and their respective agents to obtain blood from me for these tests and no others. Use of Screening Results. I understand that this biometric screening may provide a better understanding of my overall health and lifestyle habits. I further understand that this biometric screening, including any blood tests or other body measurements, is meant to be educational and is not meant to diagnose illness or replace normal health care. If I have questions about a specific illness or condition, I understand that I should consult my personal physician. Consent to Disclosure. StayWell may collect personally identifiable information about me, including, but not limited to, my name, my SSN, my date of birth, and my screening results (my "Personal Information"). My Personal Information is used by StayWell to provide health management services to me, which includes using the Personal Information to inform me of relevant health related and health education programs offered by StayWell or by another service contractor. In the event that StayWell's services are transitioned to another service provider, StayWell may deliver my Personal Information to the successor provider to maintain a continuity of services for me. I understand that the information collected and entered via this form may be transferred to StayWell by screening staff via an express carrier (UPS, FedEx, etc.) and give approval for the trackable shipment of this information and this form. StayWell and other contracted data analysis companies may also use my Personal Information as part of group statistical research and analysis. (My Personal Information will be de-identified prior to sharing with contracted data analysis companies.) I also understand that my information may be entered into my Personal Health Assessment results by StayWell. Except for these types of usage and the uses specified in my StayWell Online terms of use, my Personal Information will not be disclosed by StayWell. Use of Information and Consent to Disclosure: Dover I understand that my participation in the screening event is completely voluntary and that participation or non-participation will have no impact on my employment status. I also understand that my individual screening results will not be shared with Dover and will not be used for any employment decisions. In order to distribute any incentives associated with program participation, StayWell may provide my name/SSN to Dover or its designated representative to notify them of the fact that I am eligible for the incentive (my actual screening results will not be provided). In addition to any Personal Information disclosed as set forth above, aggregate survey results, without any identifiable Personal Information, may be made available to Dover for program reporting purposes. General Release. I agree to release and hold harmless Dover, StayWell and their respective agents or employees from any liability that may arise from my participation in this biometric screening.

Accepted and Agreed:

Signature: _____________________________________________

Date: _______________

Print Name: ___________________________________________________________________ ---------------------------------------------------------------------------- Screening Staff Only ---------------------------------------------------------------------------Your Personal Health Screening Results: Screening Exam Your Results Desirable Height feet Height inches Weight pounds Waist Measurement Systolic Blood Pressure Diastolic Blood Pressure Total Cholesterol HDL Cholesterol Glucose Critical Values Discussed Men <40 inches; Women <35 inches Under 120 mm Hg Under 80 mm Hg Less than 200 mg/dL Greater than 40 mg/dL Less than or equal to 140 mg/dL (non-fasting) Less than or equal to 100 mg/dL (fasting)

Fasting

Non-fasting

Starting January 1, 2011, log on to the Dover Health Support Services Online Health Portal at https://dover.online.staywell.com to complete your Personal Health Assessment (PHA).For additional questions or to register for a lifestyle management or disease management program, you can call Dover Health Support Services at 1-800-947-9560, option 3.
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Your Waist Circumference. Waist circumference is a measurement of fat in the abdominal area. Increased fat in the abdominal area places increased strain on the heart, often increasing your risk for developing risk factors associated to heart disease, diabetes and other diseases. The risk for developing heart and other diseases increases with a waist measurement of greater than 40 inches for men, and greater than 35 inches for women. Your Blood Pressure. The heart pumps to move blood through the body. Blood travels from the heart through blood vessels called arteries. Blood pressure is a measure of how hard the blood pushes against the artery walls as it moves through the body. If your blood pressure is high, your heart has to work harder to move blood. Blood pressure increases and decreases normally with daily activities. High blood pressure, or hypertension, occurs when your blood pressure becomes too high and stays there. High blood pressure is sometimes called the silent killer because it has no clear signs or symptoms a person can have it and not know it. High blood pressure doesnt make you feel dizzy or nervous but can cause heart disease, kidney disease and stroke. The higher your blood pressure, the higher your risk. Thats why you should have your blood pressure checked regularly. There are some risk factors for high blood pressure that you cant control, such as your family history, age, race and gender. However, you can control your eating habits by limiting foods high in salt and saturated fat, your physical activity level, your weight, tobacco use and stress level. Your Systolic and Diastolic Blood Pressure. Blood pressure is recorded as two numbers. Systolic pressure is the force of blood in the arteries as the heart beats. It is shown as the top number in a blood pressure reading. Diastolic pressure is the force of blood in the arteries as the heart relaxes between beats. It's shown as the bottom number in a blood pressure reading. If either of these numbers is too high for two or three separate readings, you may be told that you have high blood pressure. The diastolic blood pressure is an important measure of high blood pressure (hypertension), especially for younger people. As you become older, your diastolic pressure will begin to decrease and your systolic blood pressure will begin to increase and become more important. A rise in diastolic or systolic blood pressure increases your risk for heart attacks, strokes and kidney failure. Your Cholesterol. It is important to know your blood cholesterol level, as high cholesterol is a risk factor for heart disease. Cholesterol is a waxy substance that occurs naturally in all parts of the body and is required for normal functioning. Cholesterol is present in cell walls or membranes, including the brain, nerves, muscle, skin, liver, intestines and heart. Your body produces all the cholesterol it needs. Over time, too much cholesterol can build up in the walls of your arteries. This causes hardening of the arteries, and decreases the size of the opening through which blood flows. Blood carries oxygen to the heart. When the arteries that carry blood to your heart muscle become clogged, your heart doesnt get the oxygen it needs. This can result in a heart attack or coronary heart disease (CHD). The good news is that you can lower your cholesterol and risk of heart disease by changing your eating habits (all animal products contain cholesterol but plant products do NOT contain cholesterol), becoming more physically active, quitting tobacco use and managing your stress. Your HDL Cholesterol. High Density Lipoprotein (HDL) is called good cholesterol. HDL carries cholesterol in the blood from other parts of the body back to the liver, which leads to its removal from the body. HDL helps keep cholesterol from building up in the walls of the arteries. If your level of HDL cholesterol is below 40 mg/dL, you are at substantially higher risk for heart disease. The higher your HDL cholesterol, the lower risk you have of heart disease. Your Glucose. Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. During digestion, the body normally breaks down food into a form of simple sugar, called glucose. Any unused glucose circulates in the bloodstream and is stored as fat, resulting in obesity. Approximately 24 million Americans have diabetes, and one in four does not know it! If not managed properly, diabetes can damage the eyes, kidneys, heart and circulation in the hands and feet, which can be life threatening. There are some uncontrollable risk factors for diabetes, such as family history, race, gender and age. The best way to avoid developing diabetes is to lead a healthy lifestyle and avoid the risk factors you can control, such as obesity and lack of physical activity. Resources for You. www.nhlbi.nih.gov www.nutrition.gov www.fitness.gov www.diabetes.org www.cdc.gov/tobacco www.healthfinder.g

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Blood Pressure and Glucose Emergency Referral

Participant Name: _______________________________ Client/Location: _________________________________ Screener(s): ____________________________________ Date: ___________ Time: __________

Screening Vendor: ____________________ _____________________________________

Blood Pressure
Readings:

_____/_____

_____/_____

_____/_____

Your screening results are in the ______________________________ Blood Pressure classification.

Systolic <120 120-139 140-159 160-180 > 180 Diastolic And < 80 Or 80-89 Or 90-99 Or 100-120 And >120 Classification Normal Prehypertension Stage 1 hypertension Stage 2 hypertension Severe Stage 2 hypertension Recommended Action Recheck in 2 years Recheck in 1 year Recheck in 2 months Recheck within 1 week or seek medical attention immediately if additional symptoms are present* Seek medical attention immediately

*Additional symptoms include: shortness of breath; chest pain; sudden, temporary weakness or numbness of face, arms or legs; dizziness; confusion, headache; loss of vision of one eye or double vision; and/or loss of balance.
Note: If systolic and diastolic categories are different, follow recommendations for shorter time follow-up, e.g. 150/86 mmHG should be evaluated or referred to source of care within 2 months.

Stage 1 & Stage 2, no symptoms: It is recommended that you follow-up with your physician. I accept the above recommendation. I refuse the above recommendation. Stage 2 with symptoms or severe Stage 2: It is recommended that you seek medical attention immediately. It is suggested that you follow-up with your physician. You should not drive a vehicle or operate heavy machinery until you seek medical attention. I accept the above recommendation. I refuse the above recommendation.
This referral is based on the guidelines set by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (2003). Uncontrolled high blood pressure could lead to a heart attack, heart failure, stroke, kidney damage and/or other serious problems.

Glucose
Fasting value:

_____ mg/dL

Non-fasting value:

_____ mg/dL

This random blood glucose value (<50mg/dL or >300mg/dL) could result in a medical emergency. It is advisable that you not drive a vehicle or operate heavy machinery. It is recommended that you see your physician or go to the nearest emergency room. Your condition could change suddenly. Please be accompanied by another responsible adult as you seek medical assistance. I accept the above recommendation. I refuse the above recommendation.
This referral is based on the guidelines set by the American Diabetes Association, www.diabetes.org

Participant: _______________________________
Signature

Site Lead: _______________________________

Signature

_______________________________
Print

_______________________________
Print

White StayWell copy 822329

Yellow Screening copy

Pink- Participant copy

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Dover Health Education Script

Hello. My name is ____________________. I will be reviewing your health screening results with you today. Height, Weight, BMI, Waist Here are your height and weight. (Point to height and weight results.) Your height and weight are used to determine your Body Mass Index (BMI). Body Mass Index is used to determine if you are within a healthy weight range. However, it does not take into account body fat or muscle mass, so if you are very muscular, your BMI may appear high. Your BMI is (within the recommended range or outside of the recommended range) (show the participant the recommended range on the BMI chart). We will also look at your waist circumference to determine if you are within a healthy weight range. Your waist circumference is (within the recommended range or outside of the recommended range). BMI and Waist outside of the recommended range: Increased fat in the abdominal area places increased strain on the heart. Changes to your diet and increasing or varying your exercise routine can help you obtain a healthy waist and BMI. Values within range: Encourage the participant to maintain their healthy weight by practicing positive health behaviors. Blood Pressure (Point at blood pressure results): This is what your blood pressure was today. Is that about what it usually reads? (point at desirable level): This is what is considered to be a desirable level. If Desirable Reading: Less than 120/80 mm Hg You are right where you should be. To maintain this reading, continue to practice healthy lifestyle habits of healthy eating, not smoking, maintaining a healthy weight, keeping alcohol to a minimum, and exercising regularly. Moderate Risk/ Prehypertension: 120-139/80-89 mm Hg Today your blood pressure was a little above what is considered as desirable. However, a persons blood pressure may fluctuate from day to day depending on a number of factors such as stress, caffeine consumption, and if you smoke, whether or not you have just had a cigarette. I recommend having your blood pressure checked at least 2 more times in the next couple of months. If the 3 readings average out to be above 140/90, see your physician. More information is provided on the back of this page about your blood pressure. I would also encourage you to contact the toll-free StayWell HelpLine for additional tips on how to lower your blood pressure. High Risk: > or = to 140/90 mm Hg As I mentioned, this is the desirable blood pressure level (point at desirable level). High blood pressure is considered to be greater than or equal to 140/90. However, a persons blood pressure may fluctuate from day to day depending on a number of factors such as stress, caffeine consumption, and if you smoke, whether or not you have just had a cigarette. o (If 140-159/90-99): Please make an appointment with your physician to have your blood pressure re-checked within the next 2 months. I would also encourage you to contact the toll-free StayWell HelpLine for additional tips on how to lower your blood pressure. o (If 160-179/100-109): Check with a physician within the next month. I would also encourage you to contact the toll-free StayWell HelpLine for additional tips on how to lower your blood pressure. Panic Value: > or = to 180/110 mm Hg Your blood pressure reading was high today. As I mentioned, this is the desirable blood pressure level (point at desirable level) (Provide the participant with an Emergency Referral form.) Given that your reading was elevated today and significantly above what is considered to be high risk, I recommend that see your physician today as soon as possible. NOTE: Please be sure to check the box on the consent form that critical values were reviewed and that the Emergency Referral Form is completed and signed.

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Total Cholesterol It is recommended that your total cholesterol level is maintained below 200. 200-239 is considered to be moderate risk and 240 and above is considered to be high risk. This is what your value was today (point at total cholesterol level result). Desirable: <200 Your total cholesterol level is considered to be at a healthy level. Continue to exercise regularly and eat a healthy, low-fat diet that includes fiber. Moderate: 200-239 This is what your total cholesterol reading was today (point at total cholesterol level result). It is recommended that your total cholesterol level stay below 200. 200-239 is considered to be moderate risk, and 240 and above is considered to be high risk. Some things you can do to lower your cholesterol are eating a healthy, low-fat diet, increase fiber intake, and exercise regularly. High: >240 and HDL was below 40 This is what your total cholesterol reading was today (point at total cholesterol level result). It is recommended that your total cholesterol level stay below 200. 240 and above is considered to be high risk. I recommend that you see your physician for a follow-up test. Some things you can do to lower your cholesterol are eating a healthy, low-fat diet, increase fiber intake, and exercise regularly. I would also encourage you to contact the toll-free StayWell HelpLine for additional tips on how to lower your cholesterol. HDL HDL is your High Density Lipoprotein, or good cholesterol. It is helpful to remember H for Healthy. The higher the HDL the better, because HDL acts as protection against heart disease. Desirable: >60 Recommended HDL is a minimum of 40. Recommended HDL is greater than 60. The primary way to increase your HDL is through aerobic activity. Smoking tends to lower HDL. Glucose (non-fasting) Glucose is your blood sugar, which can be related to diabetes. It is recommended that a nonfasting glucose level be below 140. This was your level today (point at glucose level). Desirable: <140 Your glucose was in the desirable range today. High: Above 140 Your glucose was high today. Have you had high glucose readings in the past? (If the participant tells you he or she is diabetic, encourage him or her to continue to monitor the glucose levels and work with his or her physician. If not diabetic, refer the participant to the physician to get a glucose tolerance test.) This test was only a screening, not a diagnosis. What it does is put up a red flag to let you know if you have a high or a low reading that you should see your physician to get further testing done. It is important to have your glucose level checked every 6 months if you have a family history of diabetes. To control glucose, choose a healthy diet, be consistent with eating habits, get consistent exercise, and control your weight. Urgent: Above 300 Your glucose level was extremely high today. (Provide the participant with an Emergency Referral Form.) It was high enough that it could have an immediate impact on your health. Please see your physician as soon as possible today. I would recommend that you have someone drive you to the urgent care or emergency room. NOTE: Please be sure to check the box on the consent form that critical values were reviewed and that the Emergency Referral Form is completed and signed. Glucose (fasting) Glucose is your blood sugar, which can be related to diabetes. It is recommended that a fasting glucose level be below 100. This was your level today (point at glucose level). Desirable: <100 Your glucose was in the desirable range today. High: Above 100 Your glucose was high today. Have you had high glucose readings in the past?

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(If the participant tells you he or she is diabetic, encourage him or her to continue to monitor the glucose levels and work with his or her physician. If not diabetic, refer the participant to the physician to get a glucose tolerance test.) This test was only a screening, not a diagnosis. What it does is put up a red flag to let you know if you have a high or a low reading that you should see your physician to get further testing done. It is important to have your glucose level checked every 6 months if you have a family history of diabetes. To control glucose, choose a healthy diet, be consistent with eating habits, get consistent exercise, and control your weight. Urgent: Above 300 Your glucose level was extremely high today. (Provide the participant with an Emergency Referral Form.) It was high enough that it could have an immediate impact on your health. Please see your physician as soon as possible today. I would recommend that you have someone drive you to the urgent care or emergency room. NOTE: Please be sure to check the box on the consent form that critical values were reviewed and that the Emergency Referral Form is completed and signed. Closing (general) Here are some brochures with additional information on the topic areas we covered today (point to brochures). I encourage you to take 1-2 brochures on topic areas that you may be interested in making lifestyle changes. I encourage you to set lifestyle goals based on the information you were provided today. Remember to take your personal health assessment, which is currently available online. (Circle URL on screening consent form) This is the URL for you to complete the PHA. You may be eligible for a $100 gift card by completing the PHS and the PHA (only participants enrolled in the Dover Medical Plan). If you do not have internet access speak with your local HR office. I also encourage you to call the toll-free StayWell HelpLine to learn more about any follow-up programs you may be eligible for. StayWell offers health educational programs where you can receive your own personal health coach, receive materials by mail, or participate in a program online. (Provide the pink copy of consent form to participant.) This is a copy of your results, please keep it for your records. Lastly, we would be interested in receiving your feedback about the screening process today. If you would complete this brief evaluation form and put it face down in this stack, we would greatly appreciate it. Do you have any questions? Thanks and have a great day! (Provide the pink copy of consent form to participant.) This is a copy of your results; please keep it for your records. Lastly, we would be interested in receiving your feedback about the screening process today. If you would complete this brief evaluation form and put it face down in this stack, we would greatly appreciate it. Do you have any questions? Thanks and have a great day!

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HIPAA Violation Incident Report Information/Action

Informant Name: Date of HIPAA violation: Approximate time of violation, if known: Name of Client: Location of Client: Number of employees/eligibles at this site: Number of employees who participated in the screening: Name of contractor company: Individual name of contractor: Has the Covered Entity been notified: Have the parties/employee(s) involved been notified:

Details

Complete details of violation:

Mitigation:

StayWell Health Management:

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Pre-screening Checklist

Site: ____________________

Lead: _____________________

Date/Time: _____________________

___ Lead verified height ___ Lead verified weight ___ Lead verified blood pressure

Known Value: ________ Known Value: ________ Known Value: ________

Result: ________ Result: ________ Result (machine 1): ________ Result (machine 2): ________ Result (machine 3): ________ Result (machine 4): ________

___ Controls/optics checks run on all Cholestech machines and logged in control log ___ All supplies distributed appropriately

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Date Date ____ ____

Post-Screening Checklist
Separate copies of consent forms (white copy=StayWell, yellow copy=Vendor) Count the total number of consent forms and record number on summary slip Separate copies of Emergency Referral Forms (white copy=StayWell, yellow copy=vendor) Count the total number of Emergency Referral Forms and record number on summary slip Complete the summary slip and affix to the top of the consent form/ERF pile Place white (StayWell) copies of consents and Emergency Referral Forms with the summary slip in the provided envelope Place Screening Satisfaction Surveys in the provided envelope Place any other Protected Health Information (items to be shredded, etc.) in the provided envelope Seal the envelope(s) and label with the location name, package number (1/2, 2/2, etc.) and date. Write Confidential to StayWell on the outside of the package. Complete the provided red next day air shipping label(s) by listing the company/site location in the shipment from section of the label, completing the address and signing/dating the bottom of the label. Affix the provided red next day air shipping label(s) to the envelope(s). **Save the Shippers Copy of the Shipping Tracking Tag** The Lead staff should ship the PHI via a staffed UPS location to StayWell as soon as possible (within 24hrs of the screening) DO NOT HAND PHI TO SITE COORDINATOR!!! Discard any unused materials. The Lead staff should compose a summary of the days event, including the client name, location, total # of participants, # of ERFs, supply details, tracking numbers of supply shipments, location PHI was shipped from and issues and email it to WSH as soon as possible following the event

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Screening Summary Slip Client: Screening Location: Date: Lead Staff: # of Consent Forms: # of Emergency Referrals: Package #: /

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