In order to qualify for the tobacco-free wellness incentive credit you will need to complete the tobacco affidavit form below.  PLEASE NOTE: IF YOU ATTEND THE ON-SITE SCREENING EVENT, TOBACCO STATUS WILL BE COLLECTED ON YOUR CONSENT FORM AND YOU DO NOT NEED TO FILL OUT THIS FORM.

If your tobacco status changes at any time, you must notify Human Resources in writing as soon as possible so that the change in your tobacco status can be recorded and your tobacco free incentive is stopped.  If you earned other wellness incentive credits, those will remain in effect and you will continue to receive them.

Tobacco Cessation Resource: Contact your state's tobacco quit line.  This free resource gives you access to trained tobacco cessation specialist who formerly used tobacco: (800) QUIT-NOW (784-8669)

Stanislaus Food Products Tobacco Affidavit Form

First Name(Required)

Last Name(Required)

Email(Required)

Tobacco status categories (check only one):(Required)

I certify that I have been tobacco free* for at least 90 consecutive days and will continue to be tobacco free* through December 31, 2023.

I decline to sign the tobacco affidavit or have not been tobacco free for at least 90 consecutive days.

Date(Required)

MM slash DD slash YYYY

*Tobacco free:

Being tobacco free simply means no use of any tobacco/nicotine product, including but not limited to: cigarette, cigar, pipe electronic cigarette, personal vaporizer, electronic nicotine delivery system, or product just once on only one occasion; you are no longer tobacco free. 

Signature(Required)