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CITY OF PEQUOT LAKES <br /> 2015 WELLNESS ACTIVITY TRACKER <br /> DATE(S) <br /> ACTIVITY COMPLETED <br /> HealthPartners Online Challenges—20 points each (60 pts max) <br /> Exercise Tracker— 10 points each(120 pts max) <br /> Healthy Book Reviews— 10 points each (40 pts max) <br /> Tobacco Cessation—50 points (50 pts max) <br /> Weight Loss Program—50 points each(200 pts max) <br /> Activity Tracker— 10 points each (60 pts max) <br /> Run/Walk/Roll Event— 10 points each (30 pts max) <br /> Dental Screening—20 points (20 pts max) <br /> Eye Exam— 10 points (10 pts max) <br /> City Health Fairs—5 points each (10 pts max) <br /> TOTAL WELLNESS POINTS <br /> - Can't exceed 200 points for FT employees <br /> - Can't exceed 100 points for PT employees <br /> Employee's Signature: <br /> Today's Date: <br /> This form must be completed and submitted to Nancy Malecha. Completed forms can be <br /> submitted at any time during the year but no later than December 18, 2015. If the form is <br /> complete, the incentive award will be processed. <br />