* 1. What is your last name?

* 2. What is your first name?

* 3. What is your age?

* 4. What is your gender?

* 5. At what email address would you like to be contacted?

* 6. Please provide a contact phone number:

* 7. Are you a current student at LCC?

* 8. Do you have a medical condition causing significant chronic pain or disability?

* 9. Have you ever applied, or are you planning to apply for disability benefits based on an on-the-job injury?

* 10. Do you meet the other criteria for participation as described in the explanation provided by Dr. Bolyard and Dr. Meharg?

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