Cornerstone Care recently received a federal HRSA grant to start a new program called H.O.N.E.Y. which stands for Healthy Options, Nutrition, Exercise, and Youth. The goal of the program is to provide resources to participants that will help make healthy choices easier. Cornerstone Care will be measuring the effectiveness of our program through surveys, attendance sheets, and activity trackers (Fitbits). Please read the following information carefully. The word “you” refers to the participant.
Procedure: You will either be referred by a medical provider, school staff member, or be self-referred into the HONEY program. After completing this application, you will complete an initial interview with either a Cornerstone Care community health worker (CHW) or integrated care coordinator (ICC) to officially enroll. You will then be issued a Fitbit Inspire 2 to monitor your own health journey. Fitbits will be either returned or reissued on the date listed in the Fitbit Sign-out form. In addition, you will be eligible to seek mobile medical services. Cornerstone Care’s Mobile Medical unit will be located at each Greene County school district at regularly scheduled intervals to be seen by a medical assistant and/or nurse practitioner. Services provided during these visits include Height, Weight, Blood Pressure, other vital signs, depression screening, and discussion of any specific concerns with provider. Cornerstone Care and community partners will also be providing ancillary services, including but not limited to fitness classes, cooking classes, nutrition education, general health education classes, etc.
Fitbit Data we WILL collect: Cornerstone Care will ONLY collect data related to steps taken that are recorded within the Fitbit community group. All data will be deidentified and no one (other than the community health worker assigned to your community group) will be able to see a participant’s name associated with steps taken.
Fitbit Data we will NOT collect: Cornerstone Care will not collect data related to sleep, heart rate, GPS, Mindfulness, active minutes, miles traveled, water intake, calories burned or any tracking measure. This information can be tracked by the participant only, for the participant’s benefit.
Other information we WILL collect: Height, Weight, Age, Blood Pressure. We will also periodically be conducting short surveys (maximum 10 minutes) to assess participant’s health knowledge and to improve our program. All participant information will be deidentified.
Reasonable benefits: Participation in any activities provided through HONEY may improve your physical and/or emotional health. You may understand more about your own health habits (food choices, physical activity, etc.) and ways to improve them.
Reasonable risks: You may choose to participate in cooking classes which may lead to injuries while preparing a meal. You may choose to participate in fitness classes which may lead to injuries including, but not limited to, sore muscles, sprains, sportinduced asthma attacks, etc. There is a reasonable risk that peers may discover you are a participant in the program, which may cause social stigma.
Withdrawal from program: Your participation in HONEY is completely voluntary, and you may choose to leave at any time. You must make your decision known to your assigned Community Health Worker and return your assigned Fitbit Device within 5 business days of withdrawal. If you relocate outside of Greene County, PA, you will no longer be eligible to participate in HONEY and will have to contact your assigned CHW to relinquish your borrowed Fitbit device.
Please read the agreement below and each consent item thoroughly. Please sign your initials and date each box to give your consent OR put an “X” through any statement if you do not give consent. This signed contract will be in effect furthermore unless you complete a new agreement in the future. You may update your consent any time by completing a new agreement and returning it to: Cornerstone Care HONEY Program: 501 W. High Street, Waynesburg, PA 15370 Fax: 724-627-0726.
Fitbit Responsibility
Fitbit Data
Fitness Classes
Fitbit Premium and Fitbit Community
Mobile Medical Unit without parent/guardian present
Medical Referrals
Photo Release
Cooking Classes
COVID-19
After school activities
Transportation
Release of Liability
Next Step
A Community Health Worker (CHW) will reach out to the parent/legal guardian with follow-up questions to establish if the participant meets the criteria for this program. If eligibility is confirmed, the CHW will schedule an in-person meeting with the parent/guardian and the participant to issue a Fitbit and enroll the participant in HONEY.
Fitbit: Student Responsibility
Rules for students (under 18, or 18+ and enrolled in High School):
In order for your child to be seen on the mobile medical unit, please fill out the medical history form below.
ADMIN: REGISTRATION
Person to Notify in Case of Emergency:
Surrogate Decision Maker:
CURRENT MEDICATION LIST
PREVENTATIVE/ROUTINE HEALTH CARE
PREVENTATIVE/ROUTINE HEALTH CARE
PREVENTATIVE/ROUTINE HEALTH CARE
PREVENTATIVE/ROUTINE HEALTH CARE
PREVENTATIVE/ROUTINE HEALTH CARE
IMMUNIZATIONS
Immunization
Immunization
Immunization
Immunization
Immunization
Immunization
Immunization
Immunization
Father
Mother
Brothers or Sisters
Spouse
Children
Relatives
HAS ANY BLOOD RELATIVE EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING ILLNESSES:
Hospitalizations
Acknowledgment of Notice & Consent of Access, Communication & Disclosure of Health Information
I acknowledge that in order to provide me with complete and safe healthcare, information regarding my medications from any and all of my treating providers, may be downloaded through RX Hub, into Cornerstone Care’s record of my health information and hereby give my consent.
I acknowledge that Cornerstone Care may attempt to contact me by telephone and may leave general information regarding my health information via voicemail or answering machine and hereby give my consent.
I give my permission to Cornerstone Care, Inc. to release my Health Information to:
*Administrative refers to things such as appointment scheduling, and payment for visits or any other administrative Information
*Treatment refers to any information involved in the patient's care such as visit notes, diagnosis, labs/results or any other treatment related information (This excludes HIV/AIDS Test Results and Family Planning Services)