Employee Health Cessation Log Form
Record and track employee progress in health-related cessation efforts for workplace wellness.
Employee Full Name
*
First Name
Last Name
Employee ID Number
*
Department/Team
Cessation Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health-Related Habit or Condition Targeted
*
Current Cessation Status
*
Please Select
Ongoing
Completed
Paused
Relapsed
Reason for Cessation
Support or Resources Utilized
Employee Assistance Program
Medical Professional
Counseling Services
Peer Support Group
Online Resources
Other
Milestones Achieved or Frequency of Progress
Symptoms or Challenges Experienced
Supervisor/HR Follow-Up Actions
Additional Notes
Completion Date or Next Review Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Log
Should be Empty: