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[DOCX File]FULL ASAM ASSESSMENT - ADULT
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Amy has a 5 yr history of opioid use, beginning with prescription opioids and progressing to mixed prescription and heroin use. She has attempted multiple programs to try and manage her use and despite these attempts and escalating harmful consequences (loss of employment and independent housing), she continues to use.
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[DOC File]Race and Ethnic Data Collection Form
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Name of Owner/Managing Agent Type of Assistance or Program Title: Name of Head of Household Name of Household Member ... This information is needed to be incompliance with OMB-mandated changes to Ethnicity and Race categories for recording the 50059 Data Requirements to HUD. Owners/agents must offer the opportunity to the head and co-head of ...
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[DOCX File]Multiple Patient/Sample - Same Test - Requisition
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Name of the physician or party authorized to order testing NATIONAL PROVIDER IDENTIFIER (NPI): The NPI is a unique identification number for covered health care providers, must match with the name of the ordering party.
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[DOC File]Intake and Outcome-Based Form - NCJRS
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Ask the caller for her name, address, and her partner's name and age so that a report may be made to CPS and/or police authorities concerning under-age sexual activity. Respond without judging the caller and make a referral to the appropriate resource.
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[DOC File]SUSPECTED CHILD ABUSE REPORT
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victim’s siblings name birthdate sex ethnicity name birthdate sex ethnicity 1. 3. 2. 4. victim’s parents/guardians name (last, first, middle) birthdate or approx. age sex ethnicity address street city zip home phone business phone () name (last, first, middle) birthdate or approx. age sex ethnicity ...
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[DOC File]Advanced Placement Human Geography Name
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Why is ethnicity important to geographers? Name 5 states that have high concentrations of African Americans. Name 4 states that have high concentrations of Hispanic Americans. Name states that have high concentrations of Asian Americans. Name 4 states that have high concentrations of …
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[DOT File]7020 CDSA Referral Form
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CDSA staff complete the “For CDSA Use” box, by entering the name of the CDSA representative accepting the referral, the referral date, the IFSP due date, the name of the assigned EISC, the assignment date and check appropriate boxes for race/ethnicity information. File the form in the child’s Infant-Toddler Program record. Disposition:
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COMPANY NAME
NAICS: Name: Ethnicity: For this period: $ $ % Address: Gender: City/State/Zip: Federal ID: Contact Name: Category Group: SBE. DBE. MBE. ACDBE. WBE. OBE. Telephone Number: To date: $ % Task Order No.: Email Address: Certifying Agency: NAICS: I certify under the penalty of perjury that the information contained on this form is true and correct ...
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Suspected Child Abuse Report
SECTION C – VICTIM (One Report per Victim): Enter the victim’s name, address, telephone number, birth date or approximate age, sex, ethnicity, present location, and, where applicable, enter the school, class (indicate the teacher’s name or room number), and grade. List the primary language spoken in …
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[DOT File]470-5150 Child Welfare Services Referral Face Sheet
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Ethnicity. Name of Parent. FACS ID. Race. Ethnicity. Family Address. Family Contact Number (Phone/Cell) Is the youngest child victim in an out-of-home placement? Yes No Date of Removal from Home. Name of Placement. Is there a current Family Interaction Plan? Yes No Address of Placement. Type of Placement.
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What ethnicity is the name