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Health Station, Special Event (BEWell 101 or GuidanceResources® EAP Program presentation), and Mobile Mammography Van Requests

Use this form to request a Health Station, Mobile Mammography Van, or invite BEWell or GuidanceResources® EAP to present for a special event at your work location. All requests are reviewed internally, and completion does not guarantee that your request will be accepted.

All VBCPS employees should submit the internal form here .

I am a: *

City Employee VBCPS Employee

⚠️ Important Notice

All VBCPS employees must submit the internal form here .

Request Information

Request Type: *

Health Station Special Event (BEWell 101 or GuidanceResources® EAP Program presentation) Mobile Mammography Van

Want a mobile Health Station set-up at your next staff event? If so, check this option and submit this completed request to BEWell. BEWell staff will set up a Health Station for your event and assist employees in taking their blood pressure and weight, as well as utilize its other features.

Estimated building occupancy: *

Please consider the following requirements and specifications before submitting this request:

The requested space for the mobile mammography van should be in an accessible location in the parking lot of School or City facility for a 40-foot van (about 10 parking spaces) to maneuver in and out of the space.
Appointments take about 20 minutes, considerably less time away from the office than it would take a staff member to go to an offsite facility. It is encouraged to work with your staff to make arrangements and allow them access to this benefit.
A minimum of 10 appointments is required for the Mobile Mammography van to keep its scheduled visit.
Mobile Mammography Van staff must have access to restroom facilities.

I am the point of contact: *

Yes No

City Employee Contact

First Name: *

Last Name: *

Department: *

Work Location: *

Work Phone: *

Work Email: *

Additional Phone Contact Number:

Point of Contact

First Name: *

Last Name: *

Department: *

Work Location: *

Work Phone: *

Work Email: *

Additional Phone Contact Number:

Event Details

Please be aware that it may take up to four weeks to process request. If you have any questions or concerns please contact us at: BEWell@vbschools.com

Event Name: *

From: *

To: *

Begin Time: *

End Time: *

Set-up Begins:

Breakdown Begins:

Expected # of Attendees: *

Briefly describe the expected audience:

Location Type:

Indoors Outdoors

Location Address: *

Additional Location Details:

Choose Presentation from the topics below:

BEWell 101 - Get a brief overview of the BEWell Program (approx. 30 minutes) GuidanceResources® EAP & Work-Life - Learn more about the Employee Assistance Program (EAP) and Work-Life Services from GuidanceResources® EAP BEWell 101 + GuidanceResources® EAP & Work-Life None Other

Please specify Presentation Topic: *

Event Type: *

Open house Webinar Guest Speaker Workshop/Training Staff Meeting Awards Ceremony Other

Please specify Event Type: *

Please list any additional relevant details about this event:

Upload any supporting documentation:

Traveling Health Station

A Traveling Health Station is a temporary placement of a Health Station at your work location and will not be located there permanently.

Please be aware that it may take up to four weeks to process requests. If you have any questions or concerns, please contact BEWell at BEWell@vbschools.com.

From: *

To: *

Details:

We require the following from you in order to set up the Traveling Health Station:

Flat and level floor/surface – For set-up and safe use of the Health Station scale. Important: If your event is outdoors, a covered area is required for set-up of a Health Station, and must be provided.
Table and chair – For set-up and proper use of the Health Station iPad and blood pressure monitor.
Access to electrical outlet – To ensure consistent functioning of the Health Station.

Thank you for your request!

Your form has been submitted successfully. A member of the BEWell team will review your request and follow up within four weeks.

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