аЯрЁБс>ўџ >@ўџџџ=џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСq` №ПСbjbjqPqP ;.::? џџџџџџЄttttФФФи\ \ \ 8” <а $иmь888ьюююююю$YhСвФ84888tt4'   8pt8Фь 8ь  ЌФ є р’€8єЩ\ Ј| ь=0m “$ˆ“ “Фд88 88888Ќ^888m8888иии„\ иии\ иииttttttџџџџ  ___________________________Department of Social Services District Office ____________________ Date:________________ Customer Name:____________________ Case Manager:__________________________ Phone #:__________________ Customer ID: _______________ Part 1: To be completed by the customer Name: ____________________________________________ Address: _________________________________ Birth date _________Telephone Number: _________________ _________________________________ 1. What illness or injury keeps you from participating in an activity? ______________________________________ 2. Were you hurt while at work? Yes____ No ___ 3. What other health problems do you have?________________________________________________________ I authorize the physician or other health practitioner to release any information about my medical condition required by the State to determine eligibility for assistance. Customer’s Signature: ______________________________ Date_________________ PART 2: To be completed by Examining Physician or Health Practitioner Note to Physician or Health Practitioner: Applicants and recipients of Temporary Cash Assistance must participate in a work or educational activity unless there is an illness or disability that prevents it. We will use the information you provide to determine the patient’s ability to participate in work or education related activities. By law we do not consider pregnancy a disability. 1. Date of current examination: mm____ dd_____ yyyy__________ 2. Pregnancy Confirmed? Yes ___ No_____ EDC date: mm____ dd____ yyyy_______ 3. Is the patient receiving prenatal care? Yes___ No____ 4. Has the patient suffered a serious illness, accident or other injury that she is being treated for? Yes __No __ If yes, nature of the illness, accident or injury: _________________________________________________________________________________________ 5. Current illness or disability if other than above._____________________________________________________ Estimated date of onset:___________________ Estimated end date:________________________ 6. Based upon your evaluation is this patient impaired? Yes____ No____ If yes, how long do you expect the impairment to last? From: mm_____ dd____ yyyy_______ To: mm______ dd____ yyyy______ 7. Based upon your examination is this patient able to participate in a work or educational activity? Yes_____ No_____ 8. Are there any limitations placed on the patient’s participation? If so what limitations? _________________________________________________________________________________________ Comments: __________________________________________________________________________________________ __________________________________________________________________________________________ My signature indicates that this information is correct to the best of my knowledge. ___________________________________________________ _______________________________________ Physician or Health Care Practitioner’s Signature Printed Name Address: ________________________________________________________ Phone #____________________ License Number: ____________________________ Date: _____________________     FAMILY INVESTMENT ADMINISTRATION VERIFICATION OF PREGNANCY / PREGNANCY RELATED DISABILITY DHR/FIA 402P May 2009 9:tx}~ Ё­ЎЪфцъюії ; < W [ d i l – ˜ Ÿ   ѓчѓжчѓвЦчѓЕѓЉѓЉѓЉчЉчЉѓŒ~ŒpbpbpbhBpќ5B*CJaJphџhlXL5B*CJaJphџh7™5B*CJaJphџ hlXLhlXL5B*CJaJphџhBpќB*CJaJphџhђf@B*CJaJphџ h8hlXL>*B*CJaJphџhџoB*CJaJphџhBpќ h8h85B*CJaJphџh7™B*CJaJphџh8B*CJaJphџ _Ё< d e У ) — Э 0 5 с т 1 2 x џ ?@њњњјыјцјјјјјПППВВ­­­gdAТ &dPЦџgd]u&$d%d&d'dNЦџOЦџPЦџQЦџgd7™gdђf@ &dPЦџgd7™gd8?ОР§§§  П С Т У Ю з л р ч ъ њ ( ) o p t € С Т Ц Ч Ъ Ь Э Ю Я а ђфжђфђШфШКШфШЋœЋЋ~Ћ~Ћ~o~^Ohђf@hђf@B*CJaJphџ hђf@hђf@5B*CJaJphџh8Ch]uB*CJaJphџh8Chђf@B*CJaJphџh8Ch7™B*CJaJphџh8ChџoB*CJaJphџh8ChlXLB*CJaJphџhBpќ5B*CJaJphџhlXL5B*CJaJphџh"&5B*CJaJphџh7™5B*CJaJphџhђf@5B*CJaJphџа ї 0 4 5 d f ї ј     1 2 8 9 : ; q s | š œ   Ђ и  G T Щ џ №фиЩКфКЎКфКфК ’ ’„’ ’v vКиj^jфКЎh]uB*CJaJphџhBpќB*CJaJphџhџo5B*CJaJphџhђf@5B*CJaJphџhAТ5B*CJaJphџh7™5B*CJaJphџhAТB*CJaJphџhAТhAТB*CJaJphџhэ)hlXLB*CJaJphџhђf@B*CJaJphџh7™B*CJaJphџhэ)hђf@B*CJaJphџ џ ?@YZ]^adeflm~‚„‹‘’“Яаб5№ф№еЦфЦЗЦЈЦЈЦЈЦфЦфЦœЦ~o`ЦTHhэ)B*CJaJphџhAТB*CJaJphџhPџhэ)B*CJaJphџh]uhђf@B*CJaJphџhPџh]uB*CJaJphџh]uh]uB*CJaJphџh"&B*CJaJphџh]uh8B*CJaJphџh]uhџoB*CJaJphџh]uhэ)B*CJaJphџhPџhAТB*CJaJphџh7™B*CJaJphџh]uhAТB*CJaJphџ@’“ЯаyзиCDЂЃю'mnецчEЃЄ њњњѕшѕѕѕѕшшлввЩшРшшшшш„Л^„Лgdџo„Л^„Лgdђf@„Л^„ЛgdPџ „Л„Eџ^„Л`„Eџgdђf@ „Л„Eџ^„Л`„Eџgdэ)gdAТgdђf@5:;=>?@By}ЋВзи7BCDdjtvЂЃЌЎЦШьэі#$&'JK`aѓчѓлѓЯѓУЗУЋУœУЋУУЋУЋУ~УЯУЯУoЋчЋчЋчcЋch]uB*CJaJphџhђf@hђf@B*CJaJphџhPџhэ)B*CJaJphџhPџhPџB*CJaJphџhPџh]uB*CJaJphџhPџB*CJaJphџh/оB*CJaJphџhэ)B*CJaJphџhџoB*CJaJphџhBpќB*CJaJphџhђf@B*CJaJphџhAТB*CJaJphџ&ablmopwyАгкмсухIWЃЄ­ЎFYegНОјhѓчлЯУЯЗЯЗЯЗѓЗѓЗЯЋЯp_ЗЋЗУЗУ h/оhэ)5B*CJaJphџ h/оhџo5B*CJaJphџhBpќ5B*CJaJphџh/о5B*CJaJphџh]u5B*CJaJphџh8CB*CJaJphџhџoB*CJaJphџh/оB*CJaJphџhэ)B*CJaJphџhђf@B*CJaJphџh]uB*CJaJphџhPџB*CJaJphџ" fgОП_`Пш?ABDEGHJKlЅІђђђђђђђђђђ№№№№№№№№ЦЦ№)$$d%d&d'dNЦџOЦџPЦџQЦџa$gd8 „Л„Eџ^„Л`„Eџgdэ)hišЁЂЊ!&'>?@BCEFHIKЅІВГМНОПРСѓчлчлчлчѓчЬФРФРФРФРЏЋœœ‰Р…ЋЬhAТhŒh8Ch8CB*CJaJphџh8Chн_љB*CJaJphџhќ hџohиZу5B*CJaJphhH AjhH AUhAТhџoB*CJaJphџh8CB*CJaJphџh/оB*CJaJphџhBpќB*CJaJphџІМНОПРСђ№№№№у „Л„Eџ^„Л`„Eџgdэ) $dNЦџgd"&9 0&P1ў:pђf@Аа/ Ар=!А№"А№#h$а%ААаАK а†œV@ёџV Normal-B*CJOJQJ^J_HaJmH phџsH tH DAђџЁD Default Paragraph FontViѓџГV  Table Normal :V і4ж4ж laі (kєџС(No List 4@ђ4 иZуHeader  ЦрР!4 @4 иZуFooter  ЦрР!H™H н_љ Balloon TextCJOJQJ^JaJС џџџџџџџџџџС .џџџџ_Ё<deУ)—Э05ст12xџ?@’“ЯаyзиCDЂЃю' m n е ц ч E Ѓ Є f g О П  _ ` П ш ? 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