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Support for the Exercise is Medicine
®
Initiative is provided by:
Support for the Exercise is Medicine
®
Initiative is provided by:
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EIM Research Learning Collaborative
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EIM Pledge
* First Name:
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Race/Ethnicity:
American Indian or Alaska Native
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* Type of Healthcare Provider:
Nurse
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* Number of Years in Healthcare:
0-5
6-10
11-15
16-20
20+
* Type of Healthcare Practice:
Academic Medical Center
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Small Clinic Setting
* Choose how you would like to be involved:
Level 1 - Promoting physical activity in your healthcare setting
Level 2 - Assessing the physical activity levels of your patients
Level 3 - Prescribing physical activity and referring your patients to exercise professionals
Level 4 - Being an EIM Champion and catalyzing change in your local community and healthcare system
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Campus Recognition Application
* University/School Name:
* Supervisor/Advisor of Campus Leadership Team:
* Campus Level:
Gold
Silver
Bronze
* How does your campus meet the level requirements:
Gold level recognition is the highest level of recognition and signifies the implementation of one or several components of the EIM Solution on the University campus, with the potential of extending into the local community. Community partnerships provide real world experience for students, while providing service to the local community.
Gold level campuses must assess physical activity as a vital sign.
A Gold level campus must also be engaged in at least (1) of the following:
* My campus assesses their patients' physical activity as a vital sign?
Yes
No
* My campus is creating collaborations between university health care professionals and exercise professionals to provide physical activity prescriptions?
Yes
No
* My campus has non-clinical professionals/departments directing students, faculty, and/or staff to the recreation center for health and fitness counseling?
Yes
No
* My campus has a computer-based system to track patient participation in physical activity interventions?
Yes
No
Other:
Silver level recognition includes activities related to awareness and promotion, and incorporates education for the university’s students, faculty, staff, and health care professionals, as well as those in the surrounding community, on EIM and its mission on campus. Silver campuses are actively engaged in educating others on the EIM solution for both the treatment and prevention of long-term illness and disease. University students are educated on the aims of EIM in health care, potentially certified as EIM health fitness professionals, and guided on how they can play a role in making physical activity an integral part of health care.
Silver level campuses must be engaged in at least (3) of the following:
* My campus hosts classes that teach students the fundamentals of EIM on Campus and their potential role in fulfilling the mission of EIM?
Yes
No
* My campus trains students to educate campus community members on EIM and the importance of physical activity as medicine?
Yes
No
* My campus works with campus health services so that every health care provider discusses physical activity with every patient or client?
Yes
No
Other:
Bronze level recognition is the first step in creating the EIM initiative on Campus. These campuses bring attention to the growing need for physical activity and take action in helping to create a healthier, more active campus environment.
Bronze level campuses create awareness of the importance of exercise and regular physical activity for health and promote exercise to students, faculty, staff and the community through engagement in any of the following activities. Bronze level campuses must engage in at least (3) of the following:
* My campus hosts events that promote physical activity?
Yes
No
* My campus markets events that encourage all campus members to discuss physical activity with their health care professional?
Yes
No
* My campus has created options for exercise that are easily accessible to the campus community?
Yes
No
* My campus has completed a Mayoral, Governor, or University President EIM on Campus Month Proclamation?
Yes
No
Other:
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Moving Through Cancer Registry
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* Program Name:
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* Address 1
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Program Description
* Resource Type (check all that apply):
Clinic or Hospital (inpatient)
Community
Clinic or Hospital (outpatient)
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Cancer Exercise Professional
Digital/Online
Research Study
* What age groups are included (check all that apply)?
Adult
Pediatric
* What cancer types are included in your program?
* What stages of treatment are included (check all that apply)?
Curative
Palliative
During Treatment
Post Treatment
Rehabilitation
Prehabilitation
* Who refers into the program? (How do clients access your program?) (check all that apply)
Client
Clinician
Other
* What are the qualifications of the instructors?
* Is there a baseline safety evaluation of the client?
Yes
No
* If yes, performed by whom (check all that apply)?
Instructor
Physician
Other
* What is the program duration? (e.g.; 12 weeks, 1 year)
* What is the frequency of sessions per week?
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2
3
4
5
6
7
* Are sessions conducted in groups or individualized (check all that apply)?
Group
Individualized
* How many years has the program been running?
* How many clients go through your program per year?
* Has your program ever been evaluated or audited?
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No
* If yes, by whom?
* Please include a brief description (250 words or less) summarizing the above information:
About You
* Who filled out this form?
* What is your role in the program?
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EIM Solution
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What best describes you?
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Exercise Professional
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Contact Area Representative
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