1. What is your department name and location?

2. What is your name and title?

3. What is your work e-mail address?

4. How many employees are in your department?

5. Do you have at least one Wellness Champion on your team? (Yes or No)

6. Write a 2-4 sentence goal describing your commitment to promoting wellness habits through realistic, achievable changes.

7. Write 1 to 4 paragraphs describing how your team will accomplish this goal with grant funds.

8. Propose a budget between $200 and $1000. (Goals and activities must align with funds request.)

9. Select your team’s level of wellness practice and knowledge:

10. Which wellness practices does your department already have implemented: (Check all that apply)