Motivation: A Lifestyle Management Center

PRIVACY ACT NOTICE


The information obtained in the completion of this health assessment is used to assist Federal Occupational Health in providing health promotion services under an interagency agreement with your employing agency. The collection and use of this information is consistent with the provisions of 5 USC 552a and 5 USC 7901.

Your submission of this information is voluntary. The information will be used only for official purposes under the routine uses as explained and published in the Federal Register under OPM/GOVT-10 (the OPM system of records for employee medical files) at

http://www.federalregister.gov/articles/2010/06/21/2010-14838/privacy-act-of-1974-update-and-amend-system-of-records#h-8


The Motivation Classic® is provided by BSDI, a health promotion software company. BSDI acts as a technology provider for the health promotion program in which you are participating.

The Motivation Classic is a voluntary wellness program that is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease.  If you choose to participate in the wellness program, you will be asked to provide health information relating to your personal fitness and overall health so that the program can provide fitness and other wellness-related services to you.  You are not required to participate in the wellness program or provide your health information.  However, employees who choose to participate in the wellness program may receive an incentive from your employer.  If you would like to participate in the program but are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive from the employer, you may be entitled to a reasonable accommodation or an alternative standard.  You may request a reasonable accommodation or an alternative standard by contacting your employer.

In addition, your health information will not be sold, exchanged, transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Program or receiving an incentive.  Anyone who receives your information for purposes of providing you services as part of the Program is required to abide by the same confidentiality requirements.  The only individual(s) who will receive your personally identifiable health information are those to whom you disclose your information and those involved with helping you meet your fitness goals through the Program.

In addition, all medical information obtained through the Program will be maintained separate from your personnel records, information stored electronically will be encrypted.  Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the Program, your Employer will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the Program, nor may you be subjected to retaliation if you choose not to participate. 

I understand and agree that my use of the Motivation Classic web site and technology is voluntary and at my own risk. I understand and agree that there are risks associated with: exercise or increased activity, attempts to improve or measure my personal fitness or other abilities, dietary changes, equipment usage, class participation, outdoor or other recreational activities, and other activities that may be encouraged by or related to the use of the Motivation Classic web site and technology. I understand and agree that the challenges presented by the Motivation Classic web site and technology, whether labeled as "challenges" or not, may not be appropriate for me and that any and all attempts to meet these challenges are at my sole risk. I understand and agree that the Motivation Classic web site and technology cannot identify, recognize, understand or take into consideration my personal health status, my readiness for exercise, my dietary limitations or allergies or other factors that may influence the safety of the activities and challenges found in the Motivation Classic web site and technology and that I must bear sole responsibility, in consultation with my health care provider when needed or appropriate, for judging the safety and applicability of these activities and challenges.

Therefore, in consideration for being able to use The Motivation Classic web site and technology provided by BSDI, and in recognition that BSDI would not be able to offer this service without my full acceptance of these terms, I hereby release, discharge, and covenant not to sue in the future, BSDI, and any/all of their directors, officers, employees, agents, successors and assigns with respect to any and all claims, demands, actions, or causes of action whatsoever, including claims arising from the negligence of any person or party, and from any and all liability for any loss or property damage or personal injury of any kind, nature, or description, including death, that may arise or be sustained by me during or related to my use of the web site or participation in the programs provided by the Motivation Classic web site and technology.

BSDI hereby disclaims all warranties and conditions with respect to The Motivation Classic web site and technology, either express, implied or statutory, including, but not limited to, the implied warranties and/or conditions of merchantability, of satisfactory quality, of fitness for a particular purpose, of accuracy, of quiet enjoyment, and noninfringement of third party rights. BSDI does not warrant against interference with your enjoyment of the Motivation Classic web site and technology or the functions contained therein. BSDI does not warrant that the Motivation Classic web site and technology will meet your requirements, that the operation of the Motivation Classic web site and technology will be uninterrupted or error-free, or that defects in the Motivation Classic web site and technology will be corrected.

I agree that if a legal dispute arises out of or in relation to my participation in the Motivation Classic Program, I will attempt to settle the dispute through mediation before a mutually acceptable mediator whose name appears in the registry of names recognized by New Jersey courts as qualified persons for mediation assignments. To the extent mediation does not result in a resolution, I agree to submit the dispute to binding arbitration through the American Arbitration Association in New Jersey. I further agree that if, in spite of this agreement to submit to binding arbitration, legal action is brought involving BSDI, it will be brought in the District Court housed in Hunterdon County, New Jersey and further agree that the substantive laws of New Jersey shall apply in any action brought.

SPECIAL AUTHORIZATION REQUIREMENT FOR SPOUSES OR FAMILY MEMBERS WHO PARTICIPATE IN THE EMPLOYEE WELLNESS PROGRAM:

If you are the spouse or family member of an employee of the employer, you may be asked to provide information relating to whether you may have a disease or disorder as part of a wellness screening activity in order for you to receive more tailored wellness services as well as to qualify for a financial reward.  As a spouse or family member, you are not required to provide any other type of genetic information, such as your own family medical history or genetic test results, for you or your spouse who is employed by the employer to qualify for a financial reward.   

If you choose to provide genetic information as part of the wellness activity, please know that it is illegal for the employer to:

  • Persuade you to allow the sale, exchange, sharing, transfer or other disclosure of your genetic information or to waive the confidential protections of your genetic information;
  • Discriminate against the employee in terms of employment-related decisions, such as hiring, firing, pay, job assignments, promotions, layoffs, training, fringe benefits or other terms or conditions of employment.
  • Deny an employee or spouse a financial reward because either rthe employee or spouse fails to meet a certain blood pressure, cholesterol level or blood glucose level.

In addition, it is illegal for the employer's health plan to use your genetic information for underwriting purposes, such as to make decisions about your eligibility for health insurance benefits, the calculation of your premium or contribution amounts.

Any genetic information you provide will remain confidential and not be disclosed to the employer except in aggregate form.  That is, the employer will not receive any genetic information that identifies you as the source of that information.  The only people who will see your individually identifiable genetic information are you and the professionals providing you wellness services.  No one in the employee's workplace should have access to your individually identifiable genetic information.

Based on the foregoing and by accepting below, I hereby voluntarily agree to provide genetic information requested by BSDI for purposes of receiving more tailored wellness services that can address my unique health needs. 

 

NOTE: All material and information presented by Motivation is intended to be used for educational purposes only. The information on this site is not intended to treat, cure or prevent any condition or disease.    Copyright © 2015 BSDI.  All Rights Reserved.

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