Tobacco Attestation Form

The Tobacco Attestation Form asks employees to attest and certify to their current use or lack of tobacco use. The form can be found by going to: PeopleSoft HCM and navigating to the Wellness Tile and clicking on "Tobacco Attestation Form" on the menu on the left side of the screen. The form is open each fall from September 1 through November 30.

Your completion of the form can be immediately confirmed by going to PeopleSoft HCM and navigating to the Wellness Tile, then clicking on "Wellness Summary" on the menu on the left side of the page. There are tabs for Current, Prior and Future Benefit year on the top of the page. New hires will see the "Completed Attestation Form" check mark under the Current Year tab, those completing the form in the fall will find the check mark on the Future Year tab.

It should take anywhere from one to three minutes.

Be honest; indicate that on the Tobacco Attestation Form. To complete all requirements to obtain the monthly Wellness Premium Incentive, you must participate in a tobacco-cessation program, but quit status at the end of the cessation program is not a requirement.

Once you have completed a majority of the sessions in a multi-week group or individual cessation program, please contact Medical Director, Elizabeth Click. You will then begin to receive the monthly Wellness Premium Incentive (if you completed the other two activities by November 30th of the previous year).

For individual telephonic coaching, please call the Quit Line Program at 1-800-QUITNOW. This program that includes eight-weeks of free nicotine-replacement therapy (gum, lozenge or patch).  Coaches are available 24 hours a day to provide support for program participants.

You may also contact EAP Provider Impact Solutions to engage a cessation coach.

To obtain the Tobacco Cessation Program Incentive, you must:

  1. indicate whether or not you currently use tobacco on the Tobacco Attestation Form;
  2. tobacco users need to participate in the majority of sessions in a group or individual cessation program; and
  3. report the completion of that program by contacting the Medical Director, Elizabeth Click.

Your completion of the form can be immediately confirmed by going to PeopleSoft HCM and navigating to the Wellness Tile, then clicking on "Wellness Summary" on the menu on the left side of the page. There are tabs for Current, Prior and Future Benefit year on the top of the page. New hires will see the "Completed Attestation Form" check mark under the Current Year tab, those completing the form in the fall will find the check mark on the Future Year tab.