SEIP Health Assessment 2019 SEIP Health Assessment 2019 Question Title * 1. Your Health Assessment is 100% Confidential. The individual results of this survey may not be shared with your employer. This information can only be shared in an aggregate report of 100 or more. If you are uncomfortable filling out your Health Assessment Survey on-line, there is a paper form available. Simply see your HR representative, or contact One Stop Wellness via the information below. This survey is 100% voluntary and simply an assessment of your health. In no way is this a diagnostic tool. The more questions you answer the more accurate your score will be. If you understand your privacy please continue. Your contact information is to ensure that the results are delivered to the correct person and beyond this your survey is considered anonymous. Last Name: First Name: Home Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Home Phone Number (Include area code): Next