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it <br />1, <br />During your Work day, wh i ch, musk group (s) is/are used the <br />MOS t "? <br />Head and neick <br />Upper back, and, shoulders <br />Lower black and stomach, <br />Legs <br />Arms <br />Other <br />Cf you were g1ven time to exercise during the work day,. would you? <br />Yes No <br />Would, you prefer to exercise -in a g,r,oupi setting.? alone? <br />0 <br />The following evaluation servi I ces arle a,vailable through various Health <br />Consultants, Pleasle check (X) the services you would be interested in <br />i a <br />receiving. <br />Would you be willing to assume part of the cost of each program you <br />partil cipate in? <br />Yes No <br />What fel,e would' you pay to participate in a program? <br />$i2.0�O - $3.00 per, session <br />I I 4*00 per session <br />$4.010 - $5.00 per session <br />Thank you,. Please return, th3".s form, to your Department CoMM"ttee <br />Representative 0 <br />