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❑ Annual vision examination <br />❑ Chiropractic. physical therapy. or iniurv-prevention care <br />D Nutrition education or meetine with a nutritionist <br />❑ Financial wellness education or meeting with a financial advisor <br />❑ Avoided regular tobacco or nicotine use <br />❑ Avoided regular alcohol use <br />❑ Broke or reduced another unhealthy habit <br />❑ Practiced a healthy hobby or activity outside of work <br />❑ Other approved activity: <br />Brief description, if needed: <br />Credit Requested: ❑ 3 hours <br />4. Community Connection & Personal Growth - 3 Hours <br />Complete two approved activities: <br />❑ Volunteer service with a community . charitable. faith -based. civic. or nonprofit <br />organization <br />❑ Youth sports coach or volunteer <br />D Youth croup. scouting. mentoring. or similar vouth-service activity <br />❑ Active participation in a community group. board. or committee <br />❑ Volunteer service through Meals on Wheels. Lions. Rotary. Elks. Jaycees. CAER. or <br />similar organization <br />❑ Completed an approved class. seminar. webinar. or educational activity <br />❑ Read an approved personal -growth, leadership. wellness, or community -focused book <br />❑ Learned a new skill that supports personal growth or service to others <br />❑ Other approved activity: <br />Brief description. if needed: <br />Credit Requested: ❑ 3 hours <br />Emnlovee Certification <br />1 certify that the information submitted on this form is true and accurate. I understand that I am <br />not required to disclose private medical records, diagnoses, counseling records, treatment <br />information. medical findings. or test results. <br />Employee Signature: Date: <br />Denartment Review <br />❑ Approved <br />D Denied <br />❑ More information needed <br />Total Wellness Incentive Vacation Credit Approved: / 12 hours <br />40 <br />