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[PDF File]VR-210 -210 (9 6b5-18) -18) 5-18)
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VR-210-6b(5-18) Please read instructions on back carefully before completing form. A. Customer Identifying Information - Individual with a Disability
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[PDF File]An IRS individual taxpayer identification number (ITIN) is ...
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and treaty article number Name (see instructions) Name at birth if different . . 1a . First name. Middle name. Last name1b. First name. Middle name Last name. Applicant’s mailing address. 2. Street address, apartment number, or rural route number. If you have a P.O. box, see separate instructions. City or town, state or province, and country.
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[PDF File]Patient Health Questionnaire (PHQ-9)
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PHQ-9 Patient Depression Questionnaire For initial diagnosis: 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
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[PDF File]TINETTI BALANCE ASSESSMENT TOOL
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TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Date Indication of gait (Immediately after told to ‘go’.) Any hesitancy or multiple attempts = 0 No hesitancy = 1
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[PDF File]VAMC SLUMS Examination - School of Medicine
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SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) - A pilot study. J am Geriatri Psych ( in press). 2 3 Questions about this assessment tool? E-mail aging ...
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[PDF File]Edinburgh Postnatal Depression Scale (EPDS)
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Edinburgh Postnatal Depression Scale 1 (EPDS) Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh
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[PDF File]Form W-9 (Rev. October 2018)
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to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the
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[PDF File]SS-4 Application for Employer Identification Number
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Form SS-4 (Rev. December 2017) Department of the Treasury Internal Revenue Service . Application for Employer Identification Number (For use by employers, corporations, partnerships, trusts, estates, churches,
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[PDF File]Internal Revenue Service Go to www.irs.gov/Form1023 for ...
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Location of Purpose Clause (Page, Article, and Paragraph): 2 . a Section 501(c)(3) requires that upon dissolution of your organization, your remaining assets must be used exclusively for exempt purposes, such as charitable, religious, educational, and/or scientific purposes. Check the box on line 2a to
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[PDF File]2018 Form 1040
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Form 1040 Department of the Treasury—Internal Revenue Service . U.S. Individual Income Tax Return . 2018. OMB No. 1545-0074. IRS Use Only—Do not write or staple in this space.
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What is education article