Completed self assessment examples
[PDF File]The Mood Disorder Questionnaire (MDQ) - Overview
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The Mood Disorder Questionnaire (MDQ) - Overview The Mood Disorder Questionnaire (MDQ) was developed by a team of psychiatrists, researchers and consumer advocates to address the need for timely and accurate evaluation of bipolar disorder. Clinical Utility n The MDQ is a brief self-report instrument that takes about 5 minutes to complete.
[PDF File]COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)
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The Risk Assessment version is three pages long, with the initial page focusing on a checklist of all risk and protective factors that may apply. This page is designed to be completed following the client (caller) interview. The next two pages make up the formal assessment. The C-SSRS Risk Assessment is …
[PDF File]Disability Report- Adult
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SEND OR BRING THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
[PDF File]Form W-9 (Rev. October 2018)
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amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of …
[PDF File]MEDICAL REQUEST FOR HOME CARE HCSP- M11Q …
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Can self-administer . 1. 2. Needs reminding 2. 3. ... * Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q). Eight Helpful Hints for Accurate Completion of the Medical Request for Home Care (M-11Q) ... The completed signed copy of the M -11Q must be forwarded within 30 calendar days
[PDF File]Form NYS-45:1/19:Quarterly Combined Withholding, Wage ...
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account, call the UI Employer Hotline at 1-888-899-8810. If you are using a paid preparer or a payroll service, the section below must be completed. Checklist for mailing: • File original return and keep a copy for your records. • Complete lines 9 and 19 to ensure proper credit of payment. • Enter your withholding ID number on your ...
[PDF File]Claim for Refund and Request for Abatement Form
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Form 843 (Rev. August 2011) Department of the Treasury Internal Revenue Service . Claim for Refund and Request for Abatement See separate instructions.
[PDF File]Form N-648, Medical Certification for Disability Exceptions
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You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant. Type or print clearly in black ink. Last Name. First Name. Middle Name. Form N-648 05/23/19 Page 2. Applicant's Name USCIS A-Number. 3. Date you first examined the applicant regarding the conditions listed in ...
[PDF File]AUTHORIZATION, AGREEMENT B. Request Status …
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Electronic Requirements - An agency should only submit data for completed training that is defined as a training event for which the student has accomplished all components in the title of the event. 3. Collection of training data requires completed training events …
[PDF File]Patient Health Questionnaire (PHQ-9)
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1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity. Consider Major Depressive Disorder - if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2)
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