Sample Scorecard Template - Free Download
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SAMPLE'EMPLOYEE'SCORE CARD'
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*In!this!example,!the!employee!has!
received!at!least!84 !po ints!an d!w o uld !
be!eligible!for!the!highest!wellness!
reward.!
!
Biometric)
HRA)Result)
Points)Earned)
Points)Earned)–)
2014)HRA)
Systolic!blood!pressure!(top!number)!
Less!than!140!
25!points!
25!
Diastolic!blood!pressure!(bottom!number)!
Less!than!90!
20!points!
20!
Tobacco!use!(cotinine!test)!
No!use!of!tobacco!
15!points!
15!
Body!Mass!Index!(BMI)!
Less!than!27.5!or!10%!improvement!over!BMI!
Score!from!2013!HRA*!
15!points!
0!
LDL!Cholesterol!
Less!than!160!or!10%!improvement!over!LDL!
Cholesterol!from!2013!HRA*!
13!points!
0!
HDL!Cholesterol!
Greater!than!35!or!10%!improvement!over!HDL!
Cholesterol!from!2013!HRA*!
12!points!
0!
Health!Coaching!–!Optional!(Available!Oct.!8,!
2013!through!July!31,!2014)!
At!least!3!health!appointments!with!Agnesian!
health!coach!
Optional!15!
points!
15!
Total!Points!Available!
!
115!
!
Points!Needed!for!Highest!Wellness!Reward!
!
84!
75!**!
!
Biometric)
HRA)Result)
Points)
Available)
Points)Earned)–)
2014)HRA)
Systolic!blood!pressure!(top!number)!
Less!than!140!
25!points!
25!
Diastolic!blood!pressure!(bottom!number)!
Less!than!90!
20!points!
0!
Tobacco!use!(cotinine!test)!
No!use!of!tobacco!
15!points!
15!
Body!Mass!Index!(BMI)!
Less!than!27.5!or!10%!improvement!over!BMI!
Score!from!2013!HRA*!
15!points!
15!
LDL!Cholesterol!
Less!than!160!or!10%!improvement!over!LDL!
Cholesterol!from!2013!HRA*!
13!points!
13!
HDL!Cholesterol!
Greater!than!35!or!10%!improvement!over!HDL!
Cholesterol!from!2013!HRA*!
12!points!
12!
Health!Coaching!–!Optional!(Available!Oct.!8,!
2013!through!July!31,!2014)!
At!least!3!health!appointments!with!Agnesian!
health!coach!
Optional!15!
points!
15!
Total!Points!Available!
!
115!
!
Points!Needed!for!Highest!Wellness!Reward!
!
84!
95!*!
**In!this!example,!the!employee!
has!received!less!than!84!points!
and!would!be!eligible!for!a!lower!
wellness!reward.!
source: fdl.wi.gov
