Template for demographic forms
[DOC File]SOCIAL ASSESSMENT REPORT/SOCIAL HISTORY
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# of pages . double-spaced Points 2-4 1 point 5+ 2 points A social history report is a professional document that is frequently prepared by social workers in a variety of direct practice settings.
[DOC File]Change Request Form Example
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[This form is divided into three sections. Section 1 is intended for use by the individual submitting the change request. Section 2 is intended for use by the Project Manager to document/communicate their initial impact analysis of the requested change.
[DOC File]Case Management Assessment Form
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Please refer to original intake and assessment for any demographic information. ***** Education: Educational level: Grade School High School/GED Associates Degree. Undergraduate Degree Graduate/Post Grad. Degree . Reading Ability/Literacy: High Moderate Limited . Race/Ethnicity: Race: African American/Black Latino/Hispanic ...
[DOC File]Sample Community Survey Questions
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Belzoni & Humphreys County Strategic Plan – 74 surveys. Community Survey Questionnaire. Your answers to the following questions will help guide the effort to prepare a Strategic Master Plan for Belzoni & Humphreys County.
[DOC File]NEPA Environmental Assessment Checklist
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Demographic Character Changes. Displacement Employment and Income Patterns. Community Facilities. and Services Code Source or Documentation. Educational Facilities Commercial Facilities Health Care Social Services Solid Waste Waste Water Storm Water Water Supply Public Safety - Police - Fire - Emergency Medical Open Space and Recreation ...
[DOC File]DEMOGRAPHIC AND HEALTH SURVEY
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Demographic and Health Survey Interviewer’s Manual ICF International Calverton, Maryland October 2012 MEASURE DHS is a five-year project to assist institutions in collecting and analyzing data needed to plan, monitor, and evaluate population, health, and nutrition programs.
[DOC File]Student Information Sheet
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Title: Student Information Sheet Author: default Last modified by: default Created Date: 8/4/2007 7:56:00 PM Company: Bibb BOE Other titles: Student Information Sheet
CONSENT FORM TEMPLATE
Name and Demographic Information (age, sex, ethnicity, address, phone number, etc.) ... (HIV), hepatitis (all forms) tuberculosis, or other sexually transmitted diseases. Testing for sickle cell. Tissue samples and the data with the samples. Billing or financial information. ... CONSENT FORM TEMPLATE ...
[DOC File]Data Extraction and Assessment Form - template
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Sociodemographics Social and demographic information about a study or its participants, including economic and cultural information, location, age, gender, ethnicity, etc. Study ID A unique ID code given to an included or excluded study by the review author (e.g. first author's name and year of publication from the main report of the study).
[DOCX File]Child Adolescent Diagnostic Assessment.cdr
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Clinician, client, and parent/care taker/guardian should have a meaningful dialogue to engage and allow the client and family to express their desired treatment preferences and priorities.
[DOC File]Demographic Information Sheet - Pepperdine University
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Demographic Information Form. Instructions: Please provide a response for each of the following questions: 1. What is your age? _____ 2. What is you sex? Female ( Male (3. What is your marital status? Single ( Married ( Separated ( Divorced Widowed (4. What is your annual income (or combined annual income if you have a spouse)? ...
[DOC File]Verbatim Reflection Format
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A. Demographic information: pseudonym for the person, age, gender, religion, race and ethnicity. B. Physical dimension -- date of admission, diagnosis, brief medical history as appropriate. C. Your goals: any specific results you wanted from the encounter, anything you wanted to avoid.
[DOC File]Demographic Sheet
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Additional categories - Refer to RPE application for instructions on when additional demographic variables are acceptable. RPE_Demographics_Sheet_Aug05.doc. Title: Demographic Sheet Author: Information Technology Last modified by: James A. Graham Created Date: 8/15/2005 4:30:00 PM
[DOCX File]Employee information form - Betterteam
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Author: Paul Peters Created Date: 08/10/2017 12:59:00 Title: Employee information form Last modified by: Paul Peters Company: Microsoft Corporation
[DOCX File]School Data Analysis
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SDA Template. 1. School Data Analysis. March 2015. School Data Analysis. School Name: Click here to enter text. ... Demographic data is data that provides descriptive information about the school community. Examples may include enrollment, attendance, grade levels, race/ethnicity, gender, students with disabilities, English learners, socio ...
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