HomeMy WebLinkAboutAgenda - 02-15-2011 - 4gORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: February 15, 2011
Action Agenda
Item No.
SUBJECT: Grant Application to North Carolina Association of County Commissioners for
Wellness Program
DEPARTMENT: Human Resources PUBLIC HEARING: (Y/N) No
ATTACHMENT(S):
NCACC Grant Application
INFORMATION CONTACT:
Michael McGinnis, Human Resources
Director, 245-2552
Clarence Grier, Financial Services
Director, 245-2453
Diane Shepherd, Benefits Manager,
245-2558
PURPOSE: To authorize the submission of the County's wellness grant application to the
North Carolina Association of County Commissioners (NCACC) Risk Management Pool for
Employee Wellness Program funding; to accept any grant funds awarded; and to establish a
grant project ordinance to monitor expenditures per the grantor's request.
BACKGROUND: The NCACC provides a wellness grant for members of the risk management
pool to provide start up funds for programs members wish to implement for their employees.
Healthier employees have a greater quality of life as individuals and contribute to the health of
the organization. Healthier employees are more productive and with healthier employees and
fewer medical claims, the County can better sustain employees' health insurance coverage.
Orange County requested and received wellness grants in 2006 and 2009. Grant funding is
based on the number of employees in the member organization, to a maximum of $5,000 and
are to be used for new wellness programs. Grant funds are to be used beginning within 90
days of receiving the grant money.
In October 2009, the Board approved the submission of an NCACC wellness grant application
for $7,500 to be used for incentives for wellness activities. A variety of rewards were purchased
and distributed to employees who completed the Health Assessment. Incentives were
distributed through a drawing of the 85% of employees who took the Health Assessment, and
others were provided for participation in wellness activities, such as the Walks at Work and
"Walktober challenge." Each department was issued one or more copies of a "Stop & Go Fast
Food Nutrition Guide," and smaller individual booklets were purchased and distributed to all new
employees.
2
Additional incentives were given to participants at the Employee Appreciation/Wellness Day in
June 2010. At that event, employees had opportunities to learn healthy stretches and exercises
that could easily be performed at their work station, share healthy recipes, learn about health
related reading material, and show their commitment to healthy living. Remaining incentives
are available for use in future health and fitness challenges.
As a member of the NCACC health insurance pool, it is proposed that Orange County submit a
grant (Attachment 1) that will provide printing, materials, and incentives for the 2011 employee
wellness program referred to as SLICE (Successful Lifestyle Initiatives for County Employees).
The grant application has been discussed with members of the Health Department and
Wellness Committee of the Employee Relations Consortium.
The 2011 application describes several new wellness promotions that continue SLICE's efforts
to encourage employees to take steps towards healthier behaviors. These include two
Wellness/Appreciation Days, mini-grants for groups of employees to request assistance in
funding wellness activities, and development of a peer recognition program for employees who
serve as healthy role models.
FINANCIAL IMPACT: The grant request is for $5,000. A County match is not required. Grant
funds will be expended from March 2011-February 2012. Therefore, any funds received will be
placed in a multi-year grant project ordinance.
RECOMMENDATION(S): The Manager recommends that the Board:
1. Authorize submission of the County's wellness grant application to the North Carolina
Association of County Commissioners;
2. Accept any funds awarded; and
3. Pending grant approval, establish a grant project ordinance to monitor expenditures per
the grantor's request.
N O R T H C A R O L I N A
ASSOCIATION OF COUNTY COMMISSIONERS
Eligibility for the Wellness Grant Program
The following criteria shall apply to any member wishing to apply for a grant:
1. Any member of the Group Health Pool is eligible to apply.
2. The county who receives a wellness grant must begin the program within 90 days of
receiving the grant money.
3. Members may submit a proposal for the Wellness Grant Program at any time during
the fiscal year. Grants will run a twelve month cycle.
4. Submissions are only for new programs. No ongoing programs will be considered.
5. As a condition for receiving a grant, all applicants must have a smoking cessation
program, or include plan for one in the application.
6. All applications will be reviewed by the NCACC Risk Management Grant Committee.
7. The amount of money that a member can receive depends upon the number of
Pools in which the member participates, and the number of full-time employees the
member employs at the time of the grant application. The maximum amount that can
be awarded to a group each year is $7500.00.
8. The County Health Plan Health Education Coordinator will monitor and audit grant
compliance. Grant recipients will be required to report measurable outcomes for
each initiative entered into their timeline prior to the end of the grant cycle.
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INSTRUCTIONS FOR WELLNESS GRANT
PROGRAM SUBMISSIONS
GRANT APPLICATION
Complete the attached grant application in addition to the program description, projected budget
and timelines for the proposed wellness program.
PROGRAM DESCRIPTION
1. Provide a description of the wellness program being proposed for consideration for the
grant.
2. Provide a projected program budget for upcoming year.
3. Provide a program timeline.
PROJECTED PROGRAM BUDGET FOR THE YEAR
Present the budget by type of expenditures. Be specific:
Expenditure Cost
(List using the following categories :)
Health risk assessment screening
Hypertension screening
Smoking Cessation program
Additional Program Options (insert)
Communication Activities (insert)
Other Activities (insert)
TIMELINE FOR PROGRAM
Complete a timeline for your program and attach it to this application.
Wellness Grant Application
Member Name: Name of Person Title of Person Phone of Person
Completing Completing completing
Orange County Assessment: Assessment: Assessment:
Government
• Diane Shepherd • Benefits Manager . 919-245-2558
• Nidhi Sachdeva Senior Health 919-245-2440
Educator --
Healthy
Carolinians of
Orange County
Mailing Address: Human Resources Dept., 200 S Cameron St., Hillsborough, NC 27278
Name of person Title of person coordinating Phone of person
coordinating wellness wellness program: coordinating the wellness
program: program:
Diane Shepherd Benefits Manager 919-245-2448
The wellness The wellness program will be available only to the following
program will be department(s): N/A
available to all
employees:
Yes
No ^
List the departments who will be a part of the wellness program and the number of employees
assigned to each location. If a department does shift work, indicate the number of employees
per shift.
Department Name Number ofEmployees
Assi ned to Location
Shift Work?
A in 19
Animal Services 25
Board Of Elections 4
Asset Management, including Public
Works
40
Child Su ort Enforcement 12
Count Attorne 4
Count Commissioners 9
Count Mana er 5
Economic Develo ment 4
Emer enc Services 77 70
Environment, Agriculture, Parks &
Rec
31
Financial Services De t. 9
Health, including Environmental
Health
86
Housing, Human Relations &
Communit Develo ment
14
Human Resources 8
Information Technolo 12
Libra Services 23
Re ister of Deeds 14
Tax Administration 27
Sheriff 138 115
Social Services 148
Solid Waste & Landfill 55
Visitors Bureau 6
Grand Total 810
The following are key components for a successful wellness program. The questions
are included to help members think about the areas involved in putting together a program and
to_identify the areas that will need attention in the planning stage.
1. Support
Strong support from top management is critical in developing and maintaining a wellness
program. Please indicate the level of support from management for this program, how
management was engaged to get their support for the program and how they will be involved in
the program. Management is defined as the governing board, county manager and department
heads.
Management
6
Support for wellness activities comes from the highest levels of Orange Cou
The County Manager, Health Director and Human Resources Director are eager
to implement a variety of wellness activities that will result in healthier lives for
employees and retirees. Department directors actively support the Wellness Day
by volunteering to serve employees and support their staffs' participation on the
Health and Wellness Committee and attendance at wellness events and activities
(Employee Appreciation/Wellness Day, nutrition and fitness challenges, etc.).
Since Orange County currently provides health care at no cost to most retirees
(for life), it's hoped that by developing healthier habits as employees, health costs
for these individuals as retirees wilt be reduced.
2. Employee Committees
How have employee-based committees with representatives from management and departments
been utilized in the planning of this grant project?
Em to ee Committee
The Employee Relations Consortium Wellness Committee (WC) represents a
cross-section of departments and employees and reflects the diversity of Orange
County employees. This WC has been integral to the development of the program
plan presented here. The Committee provided key input and feedback on
proposed program components, helped select effective incentive options, and
provided information on how well the proposed components would be utilized by
employees in the departments they represent.
The Benefits Manager is the coordinator of the Wellness Committee and has had
an active role in grant preparation, as well as participating in the program planning
process.
Health Department representatives have also played an integral role in the
development of this proposal. They have provided guidance and shared their
expertise to ensure that the program components proposed are theory- and
evidence-based and based on proven strategies to encourage behavior change
amon Oran a Count Em to ees.
3. Financial Resources
The costs of a wellness program can vary according to the type of activities in the program,
whether costs are shared with employees, and what local resources are available. What type of
resources is the member willing to dedicate, will adequate funding be available?
Financial Resources
In-kind time will be donated by the following groups/persons:
Human Resources: Benefits Manager (promote health related benefits, provide
needed statistics and relevant claims information, develop programs and promote
employee wellness activities, average of sixteen hours a month).
Health Department: Sr. Health Public Educator (technical assistance and
consultation, as time allows), Registered Dietitian (technical assistance and
consultation, diabetes self-management program and medical nutritional therapy).
Employee Relations Consortium: Committee members (approximately 10 hours a
month spread among 36 ERC at large committee members and 15 Wellness
Committee Members)
In addition, meeting space is available to hold wellness events; and employees
can join the local SportsPlex at a reduced membership price. There are several
free marketing channels in place and available for use-Staff email and Human
Resources Wellness web pages (http~//server1.co.orange.nc.us/Pers/index.html
See Wellness News and Events).
Financial support is available for Wellness Days through the Human Resources
Events budget, to provide for meals.
4. Staff Time
Commitment of staff is critical for a successful wellness program. Will there be a dedicated
employee with responsibility to design, implement and coordinate the wellness program? Will
they be provided the time to set up the program, work with an employee committee, promote the
wellness program
Staff Time
The primary employee dedicated to this program is the Benefits Manager within
the Human Resources Department. This staff person chairs the Health and
Wellness subcommittee of the Employee Relations Consortium, serves as lead for
the Wellness Program, assesses the wellness needs of employees, plans
programs using best practice criteria and input from the Health Department and
Wellness Committee members, promotes and carries out programs with partners,
and evaluates the programs to ensure participation and effectiveness.
Due to budget constraints, the former chair of this committee, a Senior Public
Health Educator, has had a change in duties that severely restrict the time
available for employee wellness. The Health Promotion and Education Services
Division of the Health Department continues to provide assistance, guidance and
expertise, and staff time for employee wellness programs.
Wellness Committee members are also committed to assisting with promotion and
coordination of wellness program activities and sharing feedback regarding
employee wellness needs and interests.
5. Employee Interest
9
What are the needs and interest of employees and management and their perceptions of
workplace wellness? What methods will be used (or have been used already) to determine what
activities will engage employees of the wellness program?
Gau ing Employee and Management Interest and Perceptions
Over 90% of employees completed a Health Assessment through the
www.myciana.com website between July 2009 and March 2010. 86% of
employees expressed interest in making changes to improve their health, with
85% wishing to increase their level of physical activity. 73% indicated an interest
in losing weight and over 60% wished to improve their cholesterol. Based on the
Health Assessment, the primary risks faced by employees, in order of frequency,
are:
1. Weight
2. Blood Pressure
3. Stress
These results are comparable to those of the Health Assessments completed in
2005, which was funded by NCACC. The risk factors have remained constant.
A survey completed in August 2009 highlighted the fact that most employees
(61 % of survey participants) are aware that eating smart and moving more are
ways in which they can improve their health and reduce health care costs and
wish to make lifestyle changes.
The County Manager would like to offer wellness activities that would lead to a
reduction in health care costs. The Health Director and the Human Resources
Director are interested in keeping employees healthy so they can have a better
quality of life, be more productive and reduce absenteeism at work. The County's
goat is to improve the quality of life of Orange County employees through
prevention efforts and behavior change.
6. Communication
Employees need to know about the program and schedule of activities in order to make decisions
about participating. Employees also need to know about the central issue or problem identified
that is a trigger for the wellness program being introduced. What communication plan will assist
with educating employees about the wellness program, how do you currently inform employees
about activities or policies?
Communication
Orange SL{CE (Successful Lifestyles Initiatives for County Employees) is the
name of Orange County's Wellness Program. ft has been a consistent sponsor of
wellness activities, and is a familiar name to most employees. Employees are
continuously informed of wellness activities through various marketing channels.
Information is shared by the Employee Relations Consortium Representative from
each department; mass emails are sent and shared with those who do not have
email; and paycheck stuffers are distributed to all staff. Messages are shared in
the employee newsletter; posters/flyers are posted in common areas of county
buildings and information displays are set up at county employee events;
Wellness pages are included at the HR Website; and, most importantly, wellness
messages and events are promoted by `word of mouth' by Health and Wellness
Committee members and other employees. The Department Directors are notified
of upcoming events at their monthly meeting and asked to share with employees.
7. Incentives
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How will you motivate employees to participate in the wellness program? Are there incentives the
member is willing to use to engage employees in the program?
Incentive
Incentive items will be awarded based on program participation and achievement
of behavior goals. The greater the employee participation in challenges and
events, the more opportunities for incentives will be available. On the other hand,
there may be cases in which non-participants in challenges or events must
contribute more for a benefit than participants.
8. Program Resources
What resources are readily available for a wellness program?
Program Resources
Rooms for workshops or brown bag YES
lunchtime sessions
Rooms for exercise classes YES
YES (Due to recent
Showers construction, most newer
buildin snow have facilities,
Exercise equipment - cardio equipment, YES; Membership required
wei hts
Outdoor area for a running or walking YES
course
Access to a swimming pool YES; Membership required
Movie projector or VCR/TV YES
Staff to take blood pressures (i.e., YES
aramedics, la ex erts, or nurses
Weight scales YES (Limited)
Blood pressure monitoring equipment NO
Staff to do graphics for posters, YES (limited)
newsletters, and announcements
YES-Parks & Rec, Dept. on
Staff to lead classes A in ,and Health De ts.
Access to a nurse(s), a nutritionist, a YES
h sical fitness trainer
Community Resources to teach classes or
rovide screenin s: check all that a I
American Lung Association UNKNOWN
American Cancer Society UNKNOWN
American Heart Association UNKNOWN
Local Health Department YES
Local Hospital Resources YES
Local Physicians YES
Local Physical Therapists YES
Local Nurses YES
Local Health Club YES, County provides
discount to S orts lex
Voluntary Agencies (Specify which ones)
Local Universities YES
Local YMCA/YWCA YES
Local Vendors YES
PROGRAM DESCRIPTION
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4. Provide a description of the wellness program being proposed for consideration for the
grant.
New components:
1. Orange SLICE Superstars Employee Recognition
The 2011 Program will include awards to employees who are nominated by their peers for their
commitment to personal wellness. An "Orange SLICE Superstar" could be someone who has made
significant changes in behavior resulting in improved health or weight loss, or an individual who
consistently practices healthy behavior and is an example to others. All nominees will be recognized,
with their release, interviewed for a feature article in an employee communication and would receive
special awards. A sample nomination form is attached.
12
2. Mini-Grant Program
Groups of employees may request a grant up to $250 to be used for support of health-related activities,
such as Eat Smart Move More Weigh Less or Weight Watchers at Work, or for exercise equipment
(exercise bands, yoga mats). Employees will complete an application and submit it to the Wellness
Committee for consideration. Grants wilt be awarded based on the number of employees making the
request, number of employees expected to benefit, alignment of request with the results of the Health
Assessment's top risk areas, and level of support from the requestors and the requestors' department
director if appropriate. A sample application is attached.
3. Wellness Day(s)
Two activity-filled events will be scheduled for spring and late fall emphasizing ways to improve health by
increasing activity during the work day, eating healthier meals, drinking water, and reducing stress.
Classes will be offered in tai chi, yoga, desk exercises and on topics such as visiting a fitness center for
the first time, and nutritional lunches throughout the day. There will be outdoor activities such as jump
rope, hula hoops, and stretching demonstrations. A healthy lunch will be provided. The Orange SLICE
Superstars will be recognized at each event, as well as individuals who have participated in the
County/NCACC sponsored challenges. Employees will sponsor booths related to indoor and outdoor
activities (hunting/fishing, gardening, Sportsplex, pets, etc.) that contribute towards stress reduction.
4. Passport to Wellness
The NCACC designed passport has been revised for Orange County employees. This Challenge
encourages employees to earn points for healthy behaviors.
On-Going Programs:
Orange County Tobacco Free Program
The Orange County Tobacco Cessation Program provides information given to every new employee
along with QuitLine information. Tobacco cessation information and brochures, NC QuitLine referral
cards, and information on NCACC discounts on tobacco cessation tools (e.g. nicotine gum, patches) are
available to assist employees/members who wish to quit tobacco use. More information on the County
Health Plan benefits, including the County Health Plan's discount programs and the $0 co-pay for over
the counter tobacco cessation products are readily available to employees.
Recent signage emphasizes the Orange County Tobacco Free Zone policy in which no tobacco use is
permitted within a 50 foot radius of all Health and Human Services buildings.
Flu Clinics
We will continue to offer multiple flu clinics to members in the fall. One of these will be in conjunction
with an Employee Wellness Day. In 2010, the Human Resources and Health Department partnered to
provide immunizations to over 200 employees, retirees and their dependents.
Walking Days
Walking Days will continue to be hosted in various locations throughout the county. In 2009, we
coordinated two walks. In 2010, six walks were led by members of the Wellness Committee or other
employees. Walks will continue to be held during lunch time and will provide employees an opportunity
`to step out and step up for better health." Walkers will be encouraged to take the first steps to improve
their health, boost their energy levels and mood, learn about the benefits of walking and ways in which
they can incorporate a daily walk into their routine. Incentives for participation will be provided and will
highlight safety while walking.
Approximately 50 employees enrolled in the NCACC fall challenge, Walktober, with one employee
earning a spot in the top 25 walkers among all state-wide participants. We will continue to encourage
employees to participate in NCACC activities.
13
Maintain Don't Gain Holiday Challenge (Eat Smart Move More NC)
The Maintain Don't Gain Holiday Challenge will continue to be held each holiday season. Employees are
encouraged to sign up for the self-directed program online and will be awarded incentives for
participation. Challenge participants will have to submit proof of registration and a completed log at the
end of the challenge to qualify for prizes, but will not be judged based on if they maintained or gained
weight over the course of the program.
PROJECTED PROGRAM BUDGET FOR THE YEAR
-.-.. ..-
Categor " `Pro rc,~am Expenditure Gust
Certificates of
Achievement, Gift
Orange SLICE Superstars certificates to sporting
Incentives Promotion (12-24 individuals) goods/recreational
store, "goody bag" with
healthy cookbook, water
bottle, lunch bag, etc.
$1,500
Equipment,
Mini-Grants Maximum $250 per grant reimbursement for
classes or challenges,
etc.
$2,500
Biometric Screenings,
Massage therapists for
Promotion/health Screenings Employee Wellness Days chair massage,
decorations, printing &
copying $1,000
Total $5,000
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PROGRAM TIMELINE
2011 __ 20 12
Activity Mar. Apr May June July Aug Sept Oct. Nov Dec. Jan. Feb
Orange
County
Tobacco
Free/Great
x
x
x
x
x
x
x
x
x
x
x
x
American
Smoke-Out
Flu Clinic x x
Passport to To be Determined
Wellness
Walking
Da s x x x x x x x x x
Maintain
Don't Gain
Holiday
Challenge x x x
(Eat Smart
Move More
Messa in )
Orange
SLICE x x x x x x x x x x
Superstars
Mini-Grants x x x x x x x x x x
Employee
Wellness x x
Days
15
PROPOSAL FOR the NCACC COUNTY HEALTH PLAN
WELLNESS GRANT PROGRAM
Orange County Government is pleased to present, for approval, the following plan for an
employee wellness grant with the NCACC County Health Plan for the Year 2010-2011.
This plan was presented to the Orange County Board of County Commissioners and was
approved on , 2011.
Name of Contact for Safety/Wellness Program: Diane Shepherd
Title of Contact: Benefits Manager
Orange County Human Resources Dept.
Name of County or County Entity: Orange County Government
Address: Orange County Human Resources Department,
PO Box 8181, Hillsborough, NC 27278
Email of Contact: dshepherdCa>co.oran_ge.nc.us
Phone: 919-245-2558
Fax: 919-644-3009
Number of Full-time Employees as of the date of this grant application: 810
Total Projected Budget for Safety and Wellness Program: 5 000
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Employee being. nominated:
Department of nominee:
Employee making nomination:
Phone #:
Nomination Form
Orange SLICE Superstar
I nominate the above employee as an Orange Slice Superstar because of their ability to
Successfully Live and be Inspiring to County Employees in the following way(s):
Made significant changes to improve his/her health over the past year
Serve as a role model to the nominator and other employees
Other (briefly describe)
Explain what the individual has done to inspire you, providing as much detail as possible.
Continue on a second page if necessary. The more information you can provide, the more
likely your nominee will be selected.)
Please keep my name confidential throughout the nomination process. Yes No
Nominator Signature:
Date:
Examples of nominations are on the back of this page.
i~
Examples of Nominations
Example A:
I nominate Joe Boxer because he lost 50 pounds in the last year by working out at the
Sportsplex several times a week. He used to just watch sports on t.v. ,but now he routinely
runs and competed in his first 5K last spring. Since then, he's been in about 5 other races.
Even though he hasn't finished in the top group, his enthusiasm and persistence have inspired
me to work out more. It's time he was recognized by other people for making such a positive
change.
Example B:
I nominate Jane X. Ersize. I first got to know her in 2001 and since then, i can't think of a week
when Jane skipped her exercising. She brings her lunch to work and doesn't eat any fast food.
She's been willing to share her recipes for healthy cooking and always makes sure we have
healthy food choices at our potlucks. Even though we tease her about what she eats and
doesn't eat, she is an inspiration on how to eat better.
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ORANGE COUNTY
Mini-grant Information
Program Description
The purpose of the Orange County SLICE grant project is to enable Orange County employees
to develop health promotion programs and projects that are aimed at improving their health.
Proposal Guidelines
Proposals will be accepted from any group of three or more Orange County employees.
Applicants can request grant awards of $40 to $250. Grant funds may be used to support new
programs or expand existing programs that have a health focus.
Grants will be distributed three times in 2011: April 25, July 25, and September 25.
Applications must be received by the 1St of each month, April through September 2011.
Acceptance letters will be sent out by the 25th of each month. Any funds must be spent by
December 31, 2011, though projects can be ongoing. The same employee may not request
mini-grant funds more than once in 2011.
Applicants must submit the application form along with a proposed budget and evidence that
the application is on behalf of more than three members of the County Health Plan. If the
request if for exercise equipment, the Exercise Equipment Addendum must be submitted with
the grant application.
Reporting Requirements
Grant recipients are expected to provide a brief follow-up report including accomplishments and
results as well as an accounting of how the money was spent. Additionally, employees may be
interviewed for Orange Alive to share their experience and successes
Questions can be directed to Diane Shepherd, Benefits Manager, during the application
process or during the grant cycle at 245-2558 or dshepherdCc~co.orange.nc.us.
Please send the mini-grant application through courier to.
Diane Shepherd
Orange County Human Resources Department
Mini-Grants Review Team
A review team consisting of representatives from the Human Resources, Health, and Asset
Management Departments, and members of the Orange County Wellness Committee will
review grant proposals and determine allocation of the grant funds. Grant applicants will be
excluded from reviewing own applications from their own department due to a conflict of
interest.
FUNDING
Once a grant application is approved, the contact person will be notified. The employees
present a receipt for the expenditure(s) to the Human Resources Department. The Financial
Services Department writes a check to one individual (identified in the application) for
reimbursement, up to the amount of the approved grant.
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A few examples of projects that MAY be funded
Employees in Department of Social Services want to participate in Weight Watchers at
Work or the Eat Smart Move More program sponsored by Co-Operative Extension. They
apply for a grant of $120 so they can be reimbursed for a scale and their weekly cost.
Their commitment is making room arrangements and locating an instructor, with an
attendance requirement of 75% of the meetings in order to be reimbursed for the cost of
meetings.
• Several employees wish to purchase tools, seeds and other supplies to establish a
vegetable garden on the County grounds. Their application for $30 must show approval
from the County for use of the grounds.
• A group of employees wants to participate in a 5K charity run. They request amini-grant
to pay their entry fee(s). As documentation, they submit a copy of the 5K registration
application signed by each person in the group with the mini-grant application. If
awarded, the County reimburses the registration fees totaling $100 with proof of actual
participation.
• Organize a series of healthy cooking classes at work and use grant funds of $90 to
purchase food, cookbooks and kitchen equipment
• Start a walking group and provide pedometers, walking logs and signage at a cost of
$125 for 8 walkers, who hope to encourage others to join them.
• Work with DEAPR to organize a lunchtime exercise class and hire an instructor. Cost:
$90 for 6 weeks of classes.
• Employees want to purchase exercise equipment (fitness bands, yoga mats, free
weights, weight lifting bench) for use at their worksite. To be reimbursed up to $250, the
grant application must include an Exercise Equipment Addendum.
20
ORANGE COUNTY Mini-grant APPLICATION
Please read carefully the description of the funding guidelines before completing and submitting
this form. In order to be considered for a grant, you must use this application form.
Names of re uestin em to ees and de artment:
Name De artment/Location
1.
2.
3.
4.
5.
6.
(Additional names may be added on a separate sheet as needed.)
Project Title:
Name of Contact Person:
Email Address:
Telephone Number:
AMOUNT OF FUNDS REQUESTED: $ (Provide budget details below.)
Project Plan
Health Promotion
Briefly describe how awarding this grant will reduce the risk factors (weight loss, high blood
pressure, stress) faced by most Orange County employees.
Project Design
Describe the project that you want to carry out, including:
What do you want to accomplish or change through your project?
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How will employees demonstrate their commitment to the project (investing their own money,
time commitment, etc.)?
What are the steps you will take, or have taken, to implement your project?
What is the timeframe of your project?
Budget
Using the table below, create a project budget indicating how you will use grant funds. If you
plan to use other funds to also support this project, please indicate the amount and how you will
spend them.
Sam le Bud et
~~
8 pedometers For walking program participants (8 @ $10 each) $80
Paint & stencil Painting an attractive mural on stairwell walls to $120
encourage taking the stairs
TOTAL ~ $230
~~
TOTAL
If more explanation is needed, describe here how the funds will be used.
Evaluation
Provide a plan of how you will measure your project's success (e.g., number of program
participants, number of miles walked, number of pounds lost.)
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Continuation
Explain how your project will continue beyond the grant funds and initial award period.
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Letters of Support
Employees applying for grant funds must submit a letter of support for the project from their
Department Director if staff time or county resources will be needed. This letter should be
included with the application.
Agreement
The information contained in this application, including all attachments and support materials, is
true and accurate, to the best of my knowledge. If our application is accepted and funds are
awarded we acknowledge that acceptance of the grant funds constitutes a commitment to
complete the project as stated in the application and comply with any required administrative
responsibilities.
Project Leader/Contact signing for all participants (participants may sign as well, but a
project leader must be identified)
Name:
Signature:
Application Submission Checklist
Before you mail the application, make sure you have included everything necessary for
consideration:
^ All sections of the application are complete, including required signatures
^ Your application addresses health promotion needs in Orange County
^ Letter of support from Department Director if staff time or county resources will be
needed
^ Exercise Equipment Addendum, if appropriate
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Exercise Equipment Addendum
If mini-grant funds will be used to purchase equipment, please answer the following:
Describe equipment and the estimated total cost:
(Include as much detail as possible, including product features)
Where will it be purchased and who will purchase it:
Specify the secured location where the equipment will be located, where theft or vandalism is
unlikely:
Identify one person who will be responsible for the equipment maintenance, security,
scheduling, etc.:
Name:
Phone
Department:
Email:
Amount that employees will contribute to this purchase (excluding grant funds): $
Once a group of employees has received approval for the mini-grant, they must present a
receipt for the equipment to the Human Resources Department. The Financial Services
Department writes a check to one individual (identified above) for the amount of the approved
grant.
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Exercise Equipment Addendum
Page 2
Each employee who will use or contribute to the cost of the equipment must sign the Affidavit.
Affidavit
Any equipment purchased with grant funds becomes County property. I understand that any
contribution I may make towards the purchase of exercise equipment is non-refundable. I am
aware of the risks associated with using the equipment and will use it only as intended, keeping
my safety and that of my co-workers in mind. The equipment is available for use by County
employees only.
Name Si nature