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As a requirement of our funding agency, the Administration on Community Living, we are conducting evaluations of the Keeping Your Brain Healthy program. We would like to obtain some information from you now and again upon completion of the program.
Please complete the questions that follow. All responses are confidential. Your name on this document will be used to pair your responses today with answers you give later on. Once we have this information, we will remove your name from the documents. In preparing reports, we will summarize data and not include any information that could identify you, except with your written consent.

Question Title

* 1. Name:

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