Health Points Request Form

Use this form to request points for your participation in fitness events, blood drives, and other health-related activities hosted within your community and completed during your spare time from October 1, 2017 – September 30, 2018.


  • Only events participated in during your spare time should be reported on this form.  Events that were hosted at your work place or by Healthier at Holman should NOT be reported on this form.
  • Preventive Screenings:
    • Screenings that are eligible for 15 Health Points include:  Breast Cancer Screening, Cervical Cancer Screening, Colon Cancer Screening, Flu Vaccination, Osteoporosis Screening, Preventive Dental Visits, Prostate Cancer Screenings, Skin Cancer Screenings, Vision Exams.
    • Exception for Employees on the Holman-Sponsored Medical Plan: Employees covered by the Holman-sponsored medical plan will automatically be granted points within 4 months of completion of the the preventive screenings listed above.  Preventive Screenings completed between October 1, 2017 and June 1, 2018 will be captured.  Screenings completed between June 1, 2018 and September 30, 2018 should be reported below.
    • Special Note on Flu Shots:  Employees who receive a flu shot in their spare time, should report it for points below.  Flu Shots received at an on-site event should not be reported here.
    • All employees, regardless of medical coverage, should report Preventive Dental Visits and Vision Exams on the form below to receive points for these activities.
  • Community Service:  Employees are eligible to receive 5 Health Points for every hour of community service.

Please complete the form below to submit your activity to receive Health Points.  Submissions received after September 30, 2018 will not be awarded Health Points.  Please note that completion of this form does not confirm that points will be awarded.  A Healthier at Holman representative will be in contact with you following your submission of this request form.  Please email with any questions or concerns.

These activities are being provided as an accommodation to and for the convenience of the employees. Participation in all Healthier at Holman activities is voluntary and at the participant’s own risk. If you have any questions, email .

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Program Contact: John Senay

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