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2. LIVE WELL 365 - Wellness Activity Completion Form

   2022 Incentive Program:
   Record your completion of the following activities during 1/1/22-12/31/22 and earn a $100 wellness incentive in January of 2023!  

   Activity completion submittal is due to Human Resources by 5 p.m. on Dec. 30, 2022. Please contact HR@annatexas.gov for questions.
   
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   2023 Incentive Program: 
   Record your completion of the following activities during 1/1/23-8/31/23 and earn a $100 wellness incentive in September of 2023!  

   Activity completion submittal is due to Human Resources by 5 p.m. on Aug. 31, 2023. Please contact HR@annatexas.gov for questions.

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   BONUS: Completion of activities 1 and 2 will earn your a $150 wellness incentive from TML Well. Visit www.annatexas.gov/wellness for details.

   NOTE: Employees will receive $100 incentive via payroll deposit and will be considered taxable income by the IRS.

6. Name:*
7. Department:*
9. Phone:*
10. E-mail:*
14. 1. TML Wellbeing Survey*
18. 2. Biometric Screening*
20. I completed my Biometric Screening via (check one):*

    1. Onsite City-sponsored Event
    2. Catapult Virtual Checkup Kit
    3. Physician Office Visit (attach doctor's note)
22. NOTE:

    Physician office visits will require you to enter the following results into the TML Well Portal: Height, Weight, Blood Pressure, Glucose, Total Cholesterol, HDL, LDL, Triglycerides

26. 3. Additional Wellness Activities

    (Attach a doctor's note for Physician Office Visits)

28. Activity 1 Description:*
29. Date Completed:*
31. Activity 2 Description:*
32. Date Completed:*
36. Acknowledgement*

    1. I certify I have provided complete and accurate information.

    I understand the City of Anna may verify the information I provide. I understand if the City of Anna discovers at any time that I have failed to provide accurate information, appropriate action, up to and including termination as indicated within the City policies, may apply. 
    
     

38. Today's Date:*
42. Attach applicable doctor's notes:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field