(Amended 5/03)
Approved 1/9/02
Amended 5/03
Page 2
Idaho Panhandle National Forest’s Wellness
Plan
has been revised and approved as of 1/9/02
(Amended 5/03)
/s/ Ranotta K. McNair
Ranotta K. McNair, Forest Supervisor
Approved 1/9/02
Amended 5/03
Page 3
IDAHO PANHANDLE NATIONAL FOREST WELLNESS PLAN
(This supersedes the Wellness Program of 2002)
(Amended 5/03)
MISSION STATEMENT
The IPNF Wellness Plan is designed around wellness activities authorized in FSM 6145 and
includes providing health services and education, specific disease screening, encouraging
health maintenance, and establishment and operation of physical fitness programs. Overall
objectives encourage units to establish employee programs to promote active life-styles to
maintain mental and physical well-being, enhance an individual’s ability to lead a satisfying
and productive life both on and off the job, and reduce Forest Service costs by increasing
productivity and reducing illness and injuries. Education, prevention, and personal fitness
programs have been incorporated within the overall scope of the Wellness Plan to meet
these objectives.
1. TYPES OF PROGRAMS
a. Education Program. The objective of this program is to make employees aware of
available information and opportunities to develop and pursue healthy lifestyles that could
improve their own “wellness”. Programs may include information sessions on such subjects
as nutrition, weight control, eye care, smoking cessation, dealing with stress, etc.
www.intelihealth.com
b. Health Screening and Evaluation Program. The objective of this program is to
reduce the potential risk of illness in a community work environment and also to provide
base line data as well as health monitoring data to employees on a continuing basis. This
program offers participatory activities such as Flu vaccinations, Health Risk Appraisals,
Health Screening, and blood testing, and interpretation of the results.
c. Personal Fitness Program. The objective of this program is to improve individual
employee fitness as appropriate (i.e. weight loss, flexibility, muscle tone, aerobic capacity,
stress reduction, etc.), and encourage personal health maintenance including physical
exercise. It is required that participants in approved exercise activities adhere to all
recommended safety practices and approved equipment.
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Amended 5/03
Page 4
2. ELIGIBILITY
a. Employees: The Wellness Plan provisions are available to all employees with
continuing appointments (career, career conditional, and excepted conditional
appointments). Temporaries may participate with supervisory approval while they are in pay
status, with the exception of the non permanent full-time employees in fire status that are
in mandatory PT training during fire season.
b. Retirees and Family Members: Although an employee’s immediate family and Forest
Service retirees may not utilize Government facilities or equipment for personal fitness
activities, they are encouraged to participate in other activities described in the Wellness
Plan. If any activity has a cost per individual, family members and retirees must pay their
own fees at the Government’s negotiated rate.
c. Employees in travel status: Employees who have approved Physical Fitness
Contracts and who are in travel status may utilize Government vehicles to drive to and from
health clubs, etc., in order to continue the fitness program. Official travel time or per
diem costs for this purpose are not appropriate.
d. Termination from the Program. Failure of an employee to fulfill all requirements
of the Wellness program may be grounds for termination of that employee’s agency support
by the supervisor under the program.
3. PARTICIPATION. Participation in all programs under the IPNF Wellness Plan is
voluntary. This includes offerings under the Education, Prevention, and Personal Fitness
Programs. Time schedules and coordination with work activities need to be worked out so
they are mutually agreeable between the employee and his/her supervisor.
Self-responsibility is the key to a successful wellness program. Employees are
responsible for carrying out physical fitness activities that are approved; this includes
Government supported and personal contribution portions. Employees are also responsible
for disclosing information on personal situations and conditions that might constitute a
health risk in any approved fitness activity.
Approved 1/9/02
Amended 5/03
Page 5
The accountability between employees and supervisors will be emphasized. The
supervisor will be more accountable for work absences for the “Excused Absence Option”
through review and approval of employee’s timesheets each pay period. Supervisors are
also responsible to review and update the Physical Fitness Contract with employees annually
For participation in the Personal Fitness Program, employees will be required to complete
two forms. The first is a medical form (attached), which may require approval of their
physician. This will outline what activities the employee is released to participate in and if
a physician’s approval is required, the cost associated with that is an employee expense
(unless an approved work capacity evaluation and health screening questionnaire (HSQ) for
fire is on file). In addition, employees will be required to sign a Physical Fitness Contract
form (attached), which must be signed by the supervisor and staff or line officer.
Federal employees injured while engaging in approved fitness activities and following the
requirements of the IPNF Wellness Plan are generally covered by Worker’s Compensation
benefits provided under Federal Employees Compensation Act and administered by the
Department of Labor, Office of Worker’s Compensation Programs.
4. OPTIONS UNDER THE PERSONAL FITNESS PROGRAM. The Personal Fitness
Program offers two options, the Excused Absence option and the Health Club option, which
are explained in detail below. Under either option the employee must follow all of the
guidance listed below under SIGNING UP and APPROVED ACTIVITIES.
OPTION 1 – HEALTH CLUB MEMBERSHIP. Employees may choose any health club.
Employees will be reimbursed for their membership fees up to $100.00 quarterly. The
employees must complete all screening requirements and sign the Personal Fitness Contract.
Employees’ agree to perform approved fitness activities at the club an average of nine
times each month. Reimbursement will be paid using the form SF 1164 (see pages 15 and
16) and an accompanying original receipt. Employees not complying with any part of these
requirements will be terminated from the program. When in travel status, employees may
use alternate forms of physical fitness to meet the requirements.

No work time is approved for exercise under the Health Club option. Employees
cannot sign up for the Excused Absence and Health Club options concurrently.

Personal responsibility is a large factor in successfully managing this program.
Employees are responsible for their attendance.
Approved 1/9/02
Amended 5/03
Page 6
Listed are some thoughts you might consider when choosing a Health Club. Is the club
close to your home or work place? Convenience is vital to a lasting fitness program. Have
you visited the club during the hours you plan to use them to determine how crowded it is
and other factors important to you? Does the club have the variety and type of equipment
and amenities that you need to make your fitness program motivating and successful? Does
the club offer programs for the family? Are there any hidden costs in the club such as
towel fees, childcare fees, or locker fees?
OPTION 2 – EXCUSED ABSENCE. Employee's cannot sign up for the Excused Absence
Option and Health Club Options concurrently.
Once the Screening Form and appropriate Contract is signed the employee is eligible to use
up to 3 hours of official time each week to participate in approved activities. No official
time for a workout on any single day will be less than 15 minutes or more than 1 hour. The
intent is to encourage multiple workouts over several days. The official time used must fall
between the hours of 6 a.m. and 6 p.m at times mutually agreeable between the employee
and his/her supervisor. Excused Absence is not allowed on weekends unless that is a
scheduled workday within the employees’ normal tour of duty.
Time shall be recorded as other paid absence on the timesheet. For instance, if you
regularly work from 8 a.m. to 3:30 p.m. with 1/2 hour for lunch (7 hours) and exercise from
5 p.m. to 6 p.m., your time sheet should show the actual work time of 7 hours coded to 01
and the hour from 5pm to 6 pm coded to TC 66 until the Washington Office establishes a
wellness transaction code. Travel time is not compensable under the Wellness Program.
Following flexitime guidelines it is allowable to use time under this Excused Absence
Program and work beyond 8 hours in a day while balancing the 40 hours/week or 80
hours/payperiod requirement. It is also allowable to earn credit hours in the same week
that you use Excused Absence time under this option. Use discretion in both situations so
this option remains available.
SIGNING UP FOR OPTIONS 1 OR 2. Employees who choose to participate in either the
Excused Absence or Health Club options will need to complete a medical form and a
Physical Fitness Contract prior to any participation in the program. The questionnaire is
based on screening criteria developed by the American College of Sports Medicine and is
used to determine if it is safe for the employee to exercise. Any employee not meeting
these criteria will need their doctor’s approval before participating in the personal fitness
program. We encourage employees to consult their doctor nevertheless since our
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Amended 5/03
Page 7
questionnaire is merely a screening device. The Physical Fitness Contract is an agreement
between you and your supervisor regarding participation in the program.
APPROVED ACTIVITIES. Forest Service Manual 6145.2 requires us to identify sanctioned
fitness activities by considering the potential for injuries and the image such activities
present to the public. When reviewing activities for inclusion into or exclusion from the
Wellness Plan, three major factors were considered:
1. How the public would view the appropriateness of a particular activity were they
aware that Government money was supporting the activity(s).
2. The potential for injury or illness in the various activities in order to assess the risks
associated with potential worker’s compensation claims.
3. An overall assessment of whether the particular activity fits into the Wellness Plan’s
goals of motivating employees rather than just providing recreation.
The potential for injury is determined by a great number of variables such as age, weight,
familiarity with the activity, state of fitness and flexibility, frequency and intensity of the
exercise, competitive drive, warm-up and cool-down. Some personal fitness activities
experience frequent less serious injuries, while other activities have less frequent but
more serious injuries. Moderate intensity exercise lasting 30 minutes, four or more times a
week, provides excellent fitness and health benefits with minimal risk. High intensity
exercise is associated with increasing injury potential and those activities are not included
in the Person Fitness Program. Competitive sports events are not part of the Personal
Fitness Program.
Following is a list of approved activities under this Wellness Plan. These activities
should be performed moderately rather than in a strenuous manner. For your information,
we have also listed some activities that were considered and rejected. If there is
activities not listed below that you would like reviewed for possible inclusion into the Plan,
please submit your request in writing for consideration by the Wellness Committee (this
would include any activity, which may be approved by a participant’s physician) to ensure it
also fits into the Wellness Plan. The Wellness committee will evaluate all requests twice a
year. All activities will be done utilizing approved personal protective equipment (PPE)
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Amended 5/03
Page 8
The following examples OF NON-CONTACT/NON-COMPETITIVE
ACTIVITIES include but are not limited to:
Jogging
Rowing Machine
Aerobics
Tennis
Aerobic Walking
X-country skiing on groomed
trails
Bicycling (road)
Treadmill
Racquet Ball
Stair/Step Machine
Free Weights
Tae Kwan-Do
Skipping Rope
Stationary Bicycle
Ski Machine
Weight Machines
Swimming (in a pool)
Walking
Stretching
Tai Chi
Yoga
Pilates
Taebo
Kickboxing
Volleyball/Wallyball
Softball
Downhill Skiing
Rollerblading
X-country skiing in
hazardous situations
Table Tennis
Basketball
Telemark Skiing
Roller Skating
Mountain-biking on trails or
other off-road
Non-approved Activities
Canoeing
Dancing
Golf
Ice Skating
Contact-type Martial Arts
Soccer
5. EXPENDITURE OF FUNDS. Planned expenditure of funds for Wellness need to be
included in the Project Work Plan (PWP) system.
6. WELLNESS COMMITTEE. The Wellness committee will be comprised of at least one
member from each Zone and Nursery, one member from the Supervisor’s Office, and one
member of the union who has program responsibility for Wellness. This committee will
meet at least twice per year to manage the program and clarify issues that arise.
Approved 1/9/02
Amended 5/2003
Page 9
FSM 6145
6145 – WELLNESS. For related direction, refer to FSM 6243 for the Employee
Assistance Program covering topics on alcohol and drug abuse; FSSSM 6700 on Safety and
Health Programs for topics on occupational health and safety; FSM 6180 on compensation
for injury; and FSH 5109.17, chapter 20, for firefighter physical qualifications and
fitness. For direction on use of appropriated funds for wellness and fitness programs, see
FSM 6511.13h.
6145.01 – Authority. Title 5, United States Code, section 7901 (5 U.S.C. 7901) and Title
5, Code of Federal Regulations, Part 792 (5 CFR Part 792) provide authority to establish
preventive programs related to health (wellness). Authorized activities related to wellness
include providing health services, health education, specific disease screening, encouraging
health maintenance, and establishment and operation of physical fitness programs.
6145.02 – Objectives. Forest Service units are encouraged to establish employee
wellness programs, which promote active lifestyles to maintain mental and physical well
being, enhance an individual’s ability to lead a satisfying and productive life both on and off
the job, and reduce Forest Service costs by increasing productivity and reducing illness
and injuries.
6145.03 – Policy. It is Forest Service policy to encourage employee wellness programs,
where appropriate, to enhance employee ability to lead a satisfying and productive life and
reduce Forest Service costs through increased productivity and reduction of illness and
injury.
6145.1 – Health Risk Screening. Wellness programs should be based on health risk
screening to identify problems such as high blood pressure, high percent of body fat, use
of tobacco products, inability to cope with stress, improper nutrition (high cholesterol),
low activity or energy levels, or the inability to perform jobs safely and proficiently.
6145.2 – Physical Fitness Programs. If a unit enters a physical fitness program where
Government time is involved, the unit must develop a plan that provides for screening to
identify individuals in high-risk categories, develop an individual exercise program based on
fitness goals and benefits to the Forest Service, identification of sanctioned fitness
activities that consider the potential for injuries and the image such activities present to
the public, and program administration and monitoring to determine benefits as well as
risks.
Approved 1/9/02
Amended 5/2003
Page 10
Employees injured while participating in an agency approved physical fitness activity, even
outside duty hours, may be eligible for worker’s compensation benefits. Approved
programs must be documented and incorporate safeguards to limit the potential for injury
or illness.
6145.3 – Expenditure of Funds. (FSM 6511.13h). Expenditure of appropriated funds (for
example, for supplies or equipment) must be supported by, and consistent with, the unit’s
plan that identifies goals, benefits to the Forest Service, how and where equipment will be
used, and risk factors considered to minimize the potential for injury and liability.
Approved 1/9/02
Amended 5/2003
Page 11
MEDICAL FORM
Idaho Panhandle National Forests Wellness Plan
Participant’s Name: _____________________________ Date: ________________________
Your Doctor’s authorization is required if:
1. You are 45 years of age or older regardless of health.
2. You have indicated the presence of any of the following symptoms or conditions: (Please check
any that apply.)
____
____
____
____
____
____
____
High blood pressure (above 140/90 at screening
Cigarette smoking (within the past 5 years)
Family history of heart disease (parent, sister or brother age 50 or younger)
Diabetes Mellitus
Presently have a sedentary lifestyle
Bone or joint problems
Symptoms of coronary heart disease


To the best of my knowledge, the above categories do not apply
I have an approved HSQ on file.
___________________________ (Signature)
Authorizing Physician:
Name: _______________________________
Phone: _______________________________
To be filled out by physician:
____________________________________(PATIENT NAME) may participate in an unsupervised
exercise program offered through the U.S. Forest Service. This may include aerobic conditioning
equipment (bicycling x-country skiing, walking/running, rowing, etc.) and perhaps some muscle
conditioning (calisthenics or weight training). Please specify any recommendations, limitations, or
comments that the Forest Service, as administrators of this program, should be aware of:
Does this condition warrant re-evaluation? If so, when? _______________________
___________________________________
Physician’s Signature
________________________________________
Date
Approved 1/9/02
Amended 5/2003
Page 12
EXCUSED ABSENCE OPTION—PHYSICAL FITNESS CONTRACT
Idaho Panhandle NF’s Wellness Plan
I, _______________________________, agree to engage in the physical fitness activity(s) allowed in the
IPNF Wellness Plan under the Excused Absence Option of the Physical Fitness Program and I agree to
abide by all requirements of the Wellness Plan.
Employees are eligible to use up to 3 hours of official time each week, to participate in approved
activities. No official time for a workout on any single day will be less than 15 minutes or more than 1
hour. The intent is to encourage multiple workouts over several days. The official time used must fall
between the hours of 6 a.m. and 6 p.m. at times mutually agreeable between the employee and his/her
supervisor. Excused Absence is not allowed on weekends unless that is a scheduled workday within the
employee’s normal tour of duty. Activities chosen must be from the approved activities listed in the
Wellness Plan.
My activity(s) will be (describe):
__________________________________________________________________________________
__________________________________________________________________________________
My health objectives are:
__________________________________________________________________________________
__________________________________________________________________________________
Known health risks:
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________
Employee’s Signature
_____________________________
Date
APPROVED _____ DISAPPROVED _____ (If disapproved, state reason(s) on back)
_______________________________________
Recommended by Supervisor’s Signature
______________________________
Date
_______________________________________
Staff or Line Officer’s Signature
______________________________
Date
The supervisor must approve any deviations from this contract in advance. If you terminate participation
in the excused absence option, notify your supervisor and timekeeper in writing (IBM message is
sufficient).
Distribution of form:
Employee
Supervisor
Wellness Coordinator
Original
Copy
Copy
Approved 1/9/02
Amended 5/2003
Page 13
HEALTH CLUB OPTION—PHYSICAL FITNESS CONTRACT
Idaho Panhandle NF’s Wellness Plan
I, ______________________________________, agree to engage in the physical fitness activity(s)
allowed in the IPNF’s Wellness Plan under the health Club option of the Physical Fitness Program and I
agree to abide by all requirements of the Wellness Plan. I understand that personal responsibility is a
large factor in successfully managing this program. I understand that if I want to put my Health Club
membership on hold or terminate the membership, it is my responsibility to arrange with the Health Club.
Employees will be reimbursed for their membership fees up to $100.00 quarterly. Activities chosen must
be from the approved activities listed in the Wellness Plan. This is to be reviewed annually between
employee and supervisor.
My activity(s) will be (describe):
1. ________________________________________________________________________________
2. ________________________________________________________________________________
My health objectives are:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
Known health risks:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
______________________________________
Employee’s Signature
_____________________________
Date
APPROVED _____ DISAPPROVED _____ (If disapproved, state reason(s) on back)
_______________________________________
Recommended by Supervisor’s Signature
______________________________
Date
_______________________________________
Staff or Line Officer’s Signature
______________________________
Date
The supervisor must approve any deviations from this contract in advance. If you terminate participation
in this option notify your supervisor and timekeeper, in writing (IBM message is sufficient).
Distribution of form:
Employee
Supervisor
Wellness Coordinator
Original
Copy
Copy
OPTIONAL PHYSICAL FITNESS TIME SHEET
Employee:______________________
Option Selected: ______1
DATE
START
TIME
STOP
TIME
cc: Supervisor, Employee
______2
Home Base__________________
Activity(s) Selected__________________________
ACTIVITY/COMMENTS
Approved 1/9/02
Amended 5/2003
Page 15
Standard and Optional Forms Facsimile Handbook
SF-1164
1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE
2. VOUCHER NUMBER
CLAIM FOR REIMBURSEMENT
3. SCHEDULE NUMBER
FOR EXPENDITURES
ON OFFICIAL BUSINESS
Read the Privacy Act Statement on the back of this form.
ANT
4.
CLA
IM
a. NAME (Last, First, middle initial)
5. PAID BY
b. SOCIAL SECURITY NO.
Blue, Joe R.
111 Iron Road
Kemp ID 88888
555-11-5555
c. MAILING ADDRESS (include ZIP code)
d. OFFICE TELEPHONE NUMBER
208 888-8888
6. EXPENDITURES (If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied the claimant.)
DATE
Show appropriate code in col. (b):
A- Local travel
O
B-Telephone or telegraph, or
D
C- Other Expenses (itemized)
E
(a)
AMOUNT CLAIMED
MILEAGE
C
RATE
¢
(c) FROM
FARE
ADD
TIPS AND
OR TOLL
PER-
MISCEL-
SONS
LANEOUS
(h)
(i)
NO. OF
MILES
(Explain expenditures in specific details:)
(b)
MILEAGE
(d) TO
(e)
(f)
(g)
nd
1/02
2 Quarter
3/02
Wellness
(Receipt of
expenditure for
Each quarter is
Required)
$100.00
If additional space is required continue on the back
SUBTOTALS CARRIED FORWARD FROM THE
BACK
7. AMOUNT CLAIMED (Total of cols. (f), (g) and (I)
$
$100.00
TOTALS
8. This claim is approved. Long distance telephone calls, if shown are certified as
necessary in the interest of the Government. (Note: if long distance calls are
included, the approving official must have been authorized, in writing, by the head
of the department or agency to so certify (31 U.S.C. 680a).)
10. I certify that this claim is true and correct to the best of my knowledge and belief and that payment or credit has
not been received by me.
Sign Original Only
Sign Original Only
CLAIMANT
SIGN HERE
Joe R Blue
DATE
11. CASH PAYMENT RECEIPT
DATE
a. PAYEE (signature)
b. DATE RECEIVED
APPROVING
OFFICIAL
SIGN HERE
Supervisor’s Signature
c. AMOUNT
9. This claim is certified correct and proper for payment.
$
Sign Original Only
AUTHORIZED
CERTIFYING
OFFICER
SIGN HERE
DATE
a. PAYMENT MADE
BY CHECK NO.
ACCOUNTING CLASSIFICATION
Job Code: TTTT04
1164-210
STANDARD FORM 1164 (Rev. 11-77)
Prescribed by GSA, FPMR (CFR 41) 101-7
Approved 1/9/02
Amended 5/2003
Page 16
1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE
2. VOUCHER NUMBER
CLAIM FOR REIMBURSEMENT
3. SCHEDULE NUMBER
FOR EXPENDITURES
ON OFFICIAL BUSINESS
Read the Privacy Act Statement on the back of this form.
5. PAID BY
a. NAME (Last, First, middle initial)
b. SOCIAL SECURITY NO.
c. MAILING ADDRESS (include ZIP code)
d. OFFICE TELEPHONE NUMBER
ANT
CLA
IM
4.
6. EXPENDITURES (If fare claimed in col. (g) exceeds charge for one person, show in col. (h) the number of additional persons which accompanied the claimant.)
DATE
Show appropriate code in col. (b):
A- Local travel
O
B-Telephone or telegraph, or
D
RATE
¢
C- Other Expenses (itemized)
E
(a)
AMOUNT CLAIMED
MILEAGE
C
(b)
FARE
ADD
TIPS AND
OR TOLL
PER-
MISCEL-
SONS
LANEOUS
(h)
(i)
NO. OF
MILES
(Explain expenditures in specific details:)
(c) FROM
MILEAGE
(d) TO
(e)
If additional space is required continue on the back
SUBTOTALS CARRIED FORWARD FROM THE
BACK
7. AMOUNT CLAIMED (Total of cols. (f), (g) and (I)
$
(f)
(g)
TOTALS
8. This claim is approved. Long distance telephone calls, if shown are certified as
necessary in the interest of the Government. (Note: if long distance calls are
included, the approving official must have been authorized, in writing, by the head
of the department or agency to so certify (31 U.S.C. 680a).)
10. I certify that this claim is true and correct to the best of my knowledge and belief and that payment or credit has
not been received by me.
Sign Original Only
Sign Original Only
DATE
CLAIMANT
SIGN HERE
11. CASH PAYMENT RECEIPT
DATE
a. PAYEE (signature)
b. DATE RECEIVED
APPROVING
OFFICIAL
SIGN HERE
c. AMOUNT
9. This claim is certified correct and proper for payment.
$
Sign Original Only
AUTHORIZED
CERTIFYING
OFFICER
SIGN HERE
DATE
a. PAYMENT MADE
BY CHECK NO.
ACCOUNTING CLASSIFICATION
1164-210
STANDARD FORM 1164 (Rev. 11-77)
Prescribed by GSA, FPMR (CFR 41) 101-7