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* 1. What is your name? (please enter first and last)

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* 2. What location do you or your spouse work at?

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* 3. Please enter your current weight in pounds

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* 4. Please enter your post-assessment one mile time in minutes and seconds below. (this can be completed walking, running or swimming)

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* 5. Currently, how many days per week do you perform cardiovascular activity? (ex. running, walking, rowing, biking, etc.)

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* 6. Do you have any comments or feedback you would like to share about your participation in the program?

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