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 Main Menu > Self Service > Benefits > Tobacco Attestation Form.

Scroll to the bottom of the form to see which Benefit Year is indicated. If it still says "2018" click on the "Add Next Benefit Year" button. You want to attest for 2019. Then please read through the form and click on one answer choice. Once you click the “save” button you will have then submitted the form.

Your completion of the form can be immediately confirmed by going to PeopleSoft HCM and navigating to Main Menu > Self Service > Personal Information > Wellness Summary. At the bottom of that page, you will see each of the three wellness activities listed.  When the box next to the Tobacco Attestation Form is checked, you will know the university has confirmed your submission of the form.

It should take anywhere from two to five 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 Benefits at AskHR@case.edu. 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 Benefits Department at AskHR@case.edu

Your completion of the form will be recorded immediately. You can confirm that by going to PeopleSoft HCM and navigating to Main Menu > Self Service > Personal Information > Wellness Summary. At the bottom of that page, you will see each of the three wellness activities listed. Once the box next to Tobacco Attestation is checked , you will know the university has confirmed your submission of the form.