Wellness request form

Kaiser Permanente is committed to partnering with the University of California to support workforce health programs. In our continuing effort to do so, for 2016 we have instituted this wellness request form. The first page asks general questions about your location, the following pages ask questions about your wellness activities for which you are requesting support, and lastly there is a section for you to provide feedback. The length of the form depends on how many activities for which you are requesting support.

Your responses will serve as the basis for conversation with your KP workforce health consultant. With this information, they will reach out to you. As conduits to the myriad of KP resources, our consultants may be able to suggest additional available resources beyond our standard support. In addition, as they work with multiple employers they can also serve as good sources for wellness success stories. We look forward to another healthy and successful year in partnership with the University of California!

NOTE: If you can’t answer a question; don’t fret! We’ll be able to fill in the blanks during our follow-up conversation.


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