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* 1. Name: (Optional)

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* 2. Building Location:

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* 3. Please indicate the health/wellness topic(s) of greatest concern for you:

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* 4. Would you participate in programming/education about Nutrition, Healthy Eating, etc.?

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* 5. Would you participate in programming about Physical Activity and Exercise?

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* 6. Would you be interested in Stress Management education?

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* 7. Would you be interested in Group-based Quit Smoking Classes?

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* 8. Would you participate in a Health & Wellness Employee Challenge at the workplace?

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* 9. Would you be interested in participating on a Wellness Committee that plans health & wellness activities for our employees?

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* 10. Sometimes employees come together to form wellness groups to support each other in various activities. The groups are informal, and any employee is welcome to participate. What kind of group might you participate with on an informal basis if you knew others shared your interest? (Check all that apply)

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* 11. What is your preferred time for Wellness Activities/programs? (Choose all that apply)

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* 12. Other Interests/Suggestions? Please list any comments regarding the impact of the current Wellness Program at the Waterloo Community School District. Include how this program may have affected you personally. List any suggestions on how we can improve the current program or things you would like to see implemented.

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