LifeWork Strategies - Provider Relations

I. Eligibility: I understand and agree to the following terms (Please check):

Employer must have one or more offices located in the
State of Maryland, Virginia or the District of Columbia

Employer must offer flu vaccination to employees at one or more of its above
office locations.

Employer must complete the award application form and earn
15 out of 25 points in order to be recognized as a "Flu Fighter". There will be no ranking.

II. Recognition: I understand and agree to the following terms (Please check):

All employers will be notified of their application status in December, 2011 following
National Influenza Vaccination Week

The names of non-winning applicants will not be released.

Winning employers agree to be recognized by LWS, AHC and other program sponsors as
a “Flu Fighter” and give permission for their company’s name to be used in advertisements,
statements and promotions related to this program.

A reception will be held for the winning employers in January 2012.
Winning employers will receive a "Flu Fighter" certificate at this event.

A “best practices” report may be created and distributed based on winning employers
responses to the award application

1. Did your company offer flu vaccination to employees on-site at one or more of
your offices located in Maryland, Virginia or the District of Columbia? Yes No

2. At your worksite clinic, did you cover the cost of flu vaccination for your employees? Yes, fully for all employees
     Yes, partially, or Yes, for medical plan members only
     No, employees self paid
     Other

3. Did you allow retirees, contractors, and/or employee’s family members to participate in
your at-work clinic? Yes No

4. What other vaccination opportunities did your company promote to employees
    and their families? Check all that apply: Doctor
     Community / Hospital
     Pharmacies
     Vouchers
     Other

5. What percentage of your workforce was vaccinated against the flu this fall? Do not track
     Less than 20%
     20-40%
     41-60%
     More than 60%

6. Which of the following tools did your company use to encourage
    employees to get vaccinated against the flu? Check all that apply: Written policy
     Participation incentive
     Statement by CEO
     Posters
     Email
     Other

7. Which of the following do you provide to your employees to help prevent
    the spread of flu and contagious illness at work? Check all that apply: Paid sick leave
     Hand sanitizer
     Poster on proper hand-washing
     Surface cleanser
     Other

8. Do you have a formal workplace policy on sick leave and return
to work specific to the flu and contagious illness? Yes No

Optional: In what other ways has your company helped stop the flu in your workplace and/or in our community? (Open-ended; limit to 250 words)

Flu Fighter Award Application