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Faculty/Staff Wellness

Tobacco Attestation Form

Tobacco Attestation Form

As part of the Wellness Program, all faculty and staff with Benelect medical plan coverage through the university, or those who will add coverage for the next calendar year, are encouraged to complete the online Tobacco Attestation Form.

During open enrollment, the form can be found in HCM Main Menu - Self-Service – Benefits – Tobacco Attestation Form; visit to get started.

New hires to the university should complete the paper form included in their orientation packet. Completion of the Tobacco Attestation Form is necessary to obtain the Wellness Premium Incentive in 2016 as a Benelect plan participant.

Tobacco users need to participate in a cessation program prior to receiving the Wellness Premium Incentive.  Following completion of the cessation program, faculty and staff must notify Benefits to initiate their Wellness Premium Incentive.  Participants still may be tobacco users at the end of the cessation program. The Tobacco Cessation page of this website details current cessation options.

A reasonable alternative standard is available for tobacco users; please contact with questions.

Notice of Reasonable Alternative Standard: If a medical condition makes it unreasonably difficult for you to achieve the standards for the incentive under this program, or if it is medically inadvisable as determined by your physician or health care provider for you to attempt to achieve the standards for the incentive under this program, contact to request a reasonable alternative standard. We will work with you to provide another way to qualify for the incentive.  Recommendations of your physician or health care provider will be considered and accommodated in developing an alternative standard that is reasonable in light of your health status.