CHIP Forms

Below you see a number of forms that can be used in the CHIP program. They are provided only as a convenient resource and may require adapting to your particular situation. Some of the forms are in PDF (cannot be edited) and some are in WORD document format that can be edited and changed to fit your particular needs. Just click on the form need below and download it to your computer.

Registration Forms

Program Registration form
Participant Registration form
Program Planning Checklist PDF
Request to Participate Form

Health Risk Assessment Forms

Preparation to Complete WellBeing 360
Recording Body Measurements & Blood results PDF
Creating Access to Wellbeing 360 step-by-step (Powerpoint)

Physician/Lab Forms

Letter to Physician (participant letter to a physician following the first health risk assessment)
How to Order Your Own Blood Tests PDF

Commencement Certificate template

Commencement (Graduation)Certificate template (editable as WORD document)

CHIP Restaurant Guidelines (for restaurants offering CHIP-compliant meals)

CHIP Approved Restaurant Guidelines & Forms
Tips for Dining Out (from Assured Neace Lukens) US-based, but will provide ideas.

Miscellaneous Forms

Exercise Conversion Chart (for converting activities into equivalent steps)
Table Attendance Exercise Record
Participant Feedback
CHIP Drive instructions