Exercise Log Template


2009 Blount County Government Wellness Program
Must be received by the 10
of each month for prior month’s exercise
Name: ___________________________ Department: ____________________ Contact #: ______________
Requirement to qualify for the Wellness Incentive:
1. You must complete your annual Health Risk Assessment including lab work (lipid profile with
fasting blood sugar, requires fasting for 12 hours) at the Employee Health Care Center. Based
on the results you will be eligible to participate in the program or referred to your
physician for their medical recommendation. (This must be done annually)
2. Exercise must be a minimum of
30 minutes at least 3 times a week
to be eligible for any
incentives based on the guidelines of the program. Exercise must be a type traditionally
recognized as improving/maintaining health.
3. Complete and submit the exercise log on a monthly basis. Formal attendance records from a
health club, exercise class, organized sports team, or other organized source of exercise may be
MONTH __________________, 20___
Day of Mo. Exercise Description
Start Time
End Time
TOTAL TIME (in minutes): ________________
I certify that the above information is truthful.
Signature: _________________________________ Date submitted: _____________________________
Department Head Signature: ______________________________________ Date: __________________
Send through inter-office mail or fax 273-5783 to Jodie King in the Human Resource Department
Please check with your physician before beginning any exercise program!


00 votes

Related Articles

Related forms

Related Categories

Parent category: Miscellaneous