ࡱ> X[UVW lbjbjO O ;-a-a%=8.$R c^* ':''' ) 3>9bbdbdbdbdbdbdb$eehRb < ) ) < <b''Huc~=~=~= <''bb~= <bb~=~=~=' <~=Nbc0c~=ih&=Xih~=ih~=$ < <~= < < < < <bb~= < < <c < < < <ih < < < < < < < < < :  Address: FORMTEXT       Phone:  FORMTEXT       Evaluating RN:  FORMTEXT       Date completed:  FORMTEXT       Revision dates:  FORMTEXT       Source of information (indicate all that apply)Reason for Assessment FORMCHECKBOX  Individual FORMCHECKBOX  Baseline Assessment FORMCHECKBOX  Records FORMCHECKBOX  Program/Services Prescreening FORMCHECKBOX  Family Member: FORMCHECKBOX  Clinical Referral FORMCHECKBOX  Case Manager: FORMCHECKBOX  Discharge  FORMCHECKBOX  Change of condition FORMCHECKBOX  Provider: FORMCHECKBOX  Other:Living Situation FORMCHECKBOX  Supported Living  FORMCHECKBOX  CRS FORMCHECKBOX  Community Companion Home FORMCHECKBOX  Family Home FORMCHECKBOX  Own home FORMCHECKBOX  Community Living Arrangement FORMCHECKBOX  ICF/MR FORMCHECKBOX  Other (specify) Legal Status:  FORMCHECKBOX  Non-adjudicated  FORMCHECKBOX  Plenary guardian  FORMCHECKBOX  Limited medical guardian  FORMCHECKBOX  Conservator Contact Person: Name:  FORMTEXT       Relationship:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       E-Mail:  FORMTEXT        FORMCHECKBOX  Emergency Contact  FORMCHECKBOX  Guardian  FORMCHECKBOX  Other:  FORMTEXT       Name:  FORMTEXT       Relationship:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       E-Mail:  FORMTEXT       Employer/Day Program/School:  FORMTEXT       Contact person:  FORMTEXT       Phone:  FORMTEXT       Insurance Information:  FORMCHECKBOX  Medicaid (Title XIX) Number:  FORMTEXT        FORMCHECKBOX  Medicare Number:  FORMTEXT        FORMCHECKBOX  Private Company:  FORMTEXT       Number:  FORMTEXT       Subscriber:  FORMTEXT        FORMCHECKBOX  Medicare D Carrier:  FORMTEXT       Number:  FORMTEXT       II: Current Medical Information: Communication:  FORMCHECKBOX  Verbal  FORMCHECKBOX  Sign  FORMCHECKBOX  Written  FORMCHECKBOX  Assistive technology  FORMCHECKBOX  Non-verbal  FORMCHECKBOX  Other Primary Language:  FORMTEXT       Ambulation Status:  FORMCHECKBOX  Independent  FORMCHECKBOX  Assist  FORMCHECKBOX  Adaptive device:  FORMTEXT       Fall Risk:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Check here if assessment attached Diagnoses:  FORMTEXT       Advance Directives/DNR:  FORMTEXT        FORMCHECKBOX  None Seizure Disorder:  FORMCHECKBOX  NA  FORMCHECKBOX  Type:  FORMTEXT       Frequency:  FORMTEXT        FORMCHECKBOX  VNS History of Illnesses/Injuries/Hospitalizations (recent):  FORMTEXT       Family Health Issues:  FORMCHECKBOX  Family Health History Form attached  FORMCHECKBOX  Records Incomplete/unknown  FORMCHECKBOX  Other:  FORMTEXT       Allergies:  FORMTEXT        FORMCHECKBOX  Epipen Current Medications: (attached additional pages as needed) DrugDoseRouteTime/Freq.Date StartedReason for Use Medication concerns: (include dependency/addiction and compliance concerns, new medications in last 3 months):  FORMTEXT       Self medication assessment completed:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Check here if attached How medication administered:  FORMTEXT       Adaptive/medical equipment:  FORMCHECKBOX  Glasses  FORMCHECKBOX  Dentures  FORMCHECKBOX  Hearing Aids  FORMCHECKBOX  Other:  FORMTEXT       Bed Side Rails  FORMCHECKBOX  Yes  FORMCHECKBOX  No Specify type and frequency:  FORMTEXT       Adaptive Bed  FORMCHECKBOX  Yes  FORMCHECKBOX  No Specify:  FORMTEXT       Immunizations:  FORMCHECKBOX  Records incomplete/status unknown TypeDate GivenTypeDate GivenTetanus/diphtheria FORMTEXT      Pertussis FORMTEXT      Pneumovax FORMTEXT      Influenza FORMTEXT      Measles (Rubeola) FORMTEXT      Rubella FORMTEXT      Polio FORMTEXT      Mumps FORMTEXT      Hepatitis B*  FORMTEXT       If no Hep B vaccination list status:  FORMTEXT      Tuberculosis (PPD) FORMTEXT      Other:  FORMTEXT      Other:  FORMTEXT       Record requested date:  FORMTEXT       Diet:  FORMCHECKBOX  Regular (no restrictions)  FORMCHECKBOX  Therapeutic Diet (low cholesterol, low fat, no added salt, etc.) Specify:  FORMTEXT        FORMCHECKBOX  Enteral feeding (specify type, product and frequency):  FORMTEXT       Food and Liquid consistency:  FORMCHECKBOX  Whole (no alterations)  FORMCHECKBOX  Cut-Up (1/2x1/2x1/2)  FORMCHECKBOX  Chopped (1/4x1/4x1/4)  FORMCHECKBOX  Ground  FORMCHECKBOX  Pureed  FORMCHECKBOX  Mixed (specify):  FORMTEXT        FORMCHECKBOX  Thin liquids (non-restrictive)  FORMCHECK(*,68hrvxܳɛɍɍiQ<ɍ)hhwr B*CJOJQJ^JaJph/jhEB*OJQJU^JmHnHphu*jthVB*OJQJU^Jphh z>B*OJQJ^JphhEB*OJQJ^Jph/jhUTlB*OJQJU^JmHnHphu*jhVB*OJQJU^Jph$jhVB*OJQJU^JphhUTlB*OJQJ^Jph)h8h8B*CJOJQJ^JaJph KkdD$$Ifl0B*Z  t0644 lapytQ'$$Ifa$gdQ'l dgdwr   " $ & 0 2 ^ ` t v x  ׿ױױ׿ױױ׿tc_Ic*jhQ'hVB*OJQJU^JphhE!hQ'hEB*OJQJ^Jph!hhwr B*OJQJ^Jph*jhVB*OJQJU^Jph*j\hVB*OJQJU^JphhEB*OJQJ^Jph/jhEB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jhVB*OJQJU^Jph    ) * 8 9 : ; Q R S a b c d n o } ~  ѻѻtѻ[ѻ0jhQ'hyvB*OJQJU^Jph0j~hQ'hyvB*OJQJU^JphhE0jphQ'hyvB*OJQJU^Jph!hQ'hEB*OJQJ^Jph*jhQ'hVB*OJQJU^Jph*jhQ'hyvB*OJQJU^Jph0jhQ'hyvB*OJQJU^Jph ) Q R n hkd$$Ifl0B*Z t0644 lapytQ'$Ifl  xhh$Ifl kdf$$Ifl0B*Z t0644 lapytQ'      7 8 F ѻѻtѻ[ѻ0jhQ'hyvB*OJQJU^Jph0jhQ'hyvB*OJQJU^JphhE0jthQ'hyvB*OJQJU^Jph!hQ'hEB*OJQJ^Jph*jhQ'hVB*OJQJU^Jph*jhQ'hyvB*OJQJU^Jph0jhQ'hyvB*OJQJU^Jph ^ xhU$Ifgd z>l $Ifl kd$$Ifl0B*Z t0644 lapytQ'F G H I T ] ^ _ ` n o p q } ~ ѻ|ѻcѻJѻ0j hQ'hyvB*OJQJU^Jph0j hQ'hyvB*OJQJU^Jph0jx hQ'hyvB*OJQJU^JphhE!hQ'h z>B*OJQJ^Jph!hQ'hEB*OJQJ^Jph*jhQ'hVB*OJQJU^Jph*jhQ'hyvB*OJQJU^Jph0jjhQ'hyvB*OJQJU^Jph^ _ } xhh$Ifl kd$$Ifl0B*Z t0644 lapytQ' xbR$Ifl $$Ifa$gdQ'l kdd $$Ifl0B*Z t0644 lapytQ'       , - . / = > L M N O Z ٙ|ٙcJ0jv hQ'hyvB*OJQJU^Jph0j hQ'hyvB*OJQJU^Jph0j hQ'hyvB*OJQJU^JphhE!hQ'hEB*OJQJ^Jph*jhQ'hyvB*OJQJU^Jph0jt hQ'hyvB*OJQJU^Jph!hQ'h z>B*OJQJ^Jph*jhQ'hVB*OJQJU^Jph  = Z o\LL$Ifl $Ifgd z>l kd $$Ifl0*  t 0644 lapytQ'Z [ `PPP$Ifl kd $$IflF,D* X t06    44 lapytQ'Z [ \ j k l m ռՍt_L$hh5B*OJQJ^Jph)hhB*CJOJQJ^JaJph0jhQ'hyvB*OJQJU^Jph0jhQ'hyvB*OJQJU^Jph*jhQ'hyvB*OJQJU^Jph0jhQ'hyvB*OJQJU^Jph!hQ'hEB*OJQJ^Jph*jhQ'hVB*OJQJU^JphhE q r s `666.dgdwr )d$d%d&d'dNOPQgdkd$$IflF,D* X t06    44 lapytQ'      % & 4 5 6 7 R S a b c d q r վՓ|eN,hh5B*CJOJQJ^JaJph-jhyv5B*OJQJU^Jph-jhyv5B*OJQJU^Jph-j*hyv5B*OJQJU^Jph'jhyv5B*OJQJU^Jph-jhyv5B*OJQJU^Jph$hh5B*OJQJ^Jph-jhhV5B*OJQJU^Jphr s   :<PRT^`tvƸwawKw*jzhVB*OJQJU^Jph*jhVB*OJQJU^Jph/jhEB*OJQJU^JmHnHphu*jhVB*OJQJU^Jph$jhVB*OJQJU^JphhEB*OJQJ^JphhE5B*OJQJ^Jph$hwr hE5B*OJQJ^Jph,h~h~5B*CJOJQJ^JaJphs b  D02`bPRdhgddhgdwr dhgd9ldgdwr 02468Zhj׿ױױ׿ױw`Lw9ww$hwr hE5B*OJQJ^Jph'jhyv5B*OJQJU^Jph-jhyv5B*OJQJU^Jphh z>5B*OJQJ^Jph'jhV5B*OJQJU^Jph*jbhVB*OJQJU^JphhEB*OJQJ^Jph/jhEB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jhVB*OJQJU^Jph oUEhE5B*OJQJ^Jph2jh z>5B*OJQJU^JmHnHphu-j@hV5B*OJQJU^Jph$hwr hE5B*OJQJ^Jph-jhyv5B*OJQJU^Jphh z>5B*OJQJ^Jph'jhV5B*OJQJU^Jph'jhyv5B*OJQJU^Jph-jPhyv5B*OJQJU^Jph  .02<>ln2۲ȚۄȚnȚXȚ*jhVB*OJQJU^Jph*jhVB*OJQJU^Jph*j*hVB*OJQJU^Jph/jhEB*OJQJU^JmHnHphu*jhVB*OJQJU^Jph$jhVB*OJQJU^JphhEB*OJQJ^Jph,hhwr 5B*CJOJQJ^JaJph 246@BDlz~  ",.0׿ױױx׿ױױb׿ױױL׿ױ*jhVB*OJQJU^Jph*jrhVB*OJQJU^Jph*jhVB*OJQJU^Jphh z>5B*OJQJ^Jph$hwr hE5B*OJQJ^JphhEB*OJQJ^Jph/jhEB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jhVB*OJQJU^Jph02^`bdǰyfP8/jhEB*OJQJU^JmHnHphu*jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*j^hyvB*OJQJU^JphhEB*OJQJ^Jph$jhVB*OJQJU^Jph,hhwr 5B*CJOJQJ^JaJphhE5B*OJQJ^Jph$hwr hE5B*OJQJ^Jph)hhEB*CJOJQJ^JaJph^`tvx 46ĶĶĈĶĶrĶĶ\ĈĶĶF*j"hVB*OJQJU^Jph*jhVB*OJQJU^Jph*j6hyvB*OJQJU^Jph/jhEB*OJQJU^JmHnHphu*jhVB*OJQJU^JphhEB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jJhyvB*OJQJU^Jph68BDhj~ (*>@BLNPDZǛr\*jhVB*OJQJU^Jph*jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jhyvB*OJQJU^Jph*jhVB*OJQJU^JphhEB*OJQJ^Jph/jhEB*OJQJU^JmHnHphu$jhVB*OJQJU^JphPR\(*FHJװyfPf:f*j\ hyvB*OJQJU^Jph*jhyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*jphyvB*OJQJU^Jph$jhVB*OJQJU^Jphhwr B*OJQJ^Jph$hRfyh9l5B*OJQJ^Jph'h(h9l5>*B*OJQJ^Jph$hoh9l5B*OJQJ^Jph)hhwr B*CJOJQJ^JaJphJLfh:<>@rtɶߠߊt\/jhwr B*OJQJU^JmHnHphu*j4"hVB*OJQJU^Jph*j!hyvB*OJQJU^Jph*jH!hyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*j hyvB*OJQJU^Jphhwr B*OJQJ^Jph$jhVB*OJQJU^Jph$&(*BD`bdfĶĶĶĶĶĶt\ĶNĶh z>B*OJQJ^Jph/jhwr B*OJQJU^JmHnHphu*j $hVB*OJQJU^Jph*j#hyvB*OJQJU^Jph*j #hyvB*OJQJU^Jphhwr B*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*j"hyvB*OJQJU^Jph "$&(468TVXZĶĶĶv`vMĶ$hohwr 5B*OJQJ^Jph*jn%hyvB*OJQJU^Jphh B*OJQJ^Jph*j$hyvB*OJQJU^JphhB*OJQJ^Jphh z>B*OJQJ^Jphhwr B*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*j$hyvB*OJQJU^Jph "68:DF"&(׿ױױ׿ױzױdQױCh(B*OJQJ^Jph$jhyvB*OJQJU^Jph*j&hyvB*OJQJU^JphhoB*OJQJ^Jph*j\&hVB*OJQJU^Jph$hohwr 5B*OJQJ^Jphhwr B*OJQJ^Jph/jhwr B*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*j%hVB*OJQJU^Jph(*&v$d$Ifa$gdQ'l dgd(dgddgdogdwr dhgddhgdwr (DFHJZ\xz|~ȵȵq[q*j(hVB*OJQJU^Jph/jhwr B*OJQJU^JmHnHphu*j4(hVB*OJQJU^Jph*j'hyvB*OJQJU^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jH'hyvB*OJQJU^Jphhwr B*OJQJ^Jph(*Ķ{ĶeMĶ8)hhoB*CJOJQJ^JaJph/jhwr B*OJQJU^JmHnHphu*j)hVB*OJQJU^Jph%hohwr B*CJOJQJ^Jph$hohwr 5B*OJQJ^Jph)hhwr B*CJOJQJ^JaJphhwr B*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*j )hyvB*OJQJU^JphjlǰyfPf:f*j*hyvB*OJQJU^Jph*j*hyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*j *hyvB*OJQJU^Jph$jhVB*OJQJU^JphhoB*OJQJ^Jph,hho5B*CJOJQJ^JaJphho5B*OJQJ^Jph$hoho5B*OJQJ^Jph)hhB*CJOJQJ^JaJph"$&8<>RTV`bvxްޢyްcP$jhyvB*OJQJU^Jph*jZ,hyvB*OJQJU^Jph*j+hVB*OJQJU^Jph$hoho5B*OJQJ^Jphh9lB*OJQJ^Jph/jhoB*OJQJU^JmHnHphu*jn+hVB*OJQJU^Jph$jhVB*OJQJU^JphhoB*OJQJ^Jphtv      * , 8 : F H J ¯qmqmqmqmqm\X\XC)h~h(B*CJOJQJ^JaJphh9l!hQ'h9lB*OJQJ^Jphh(!hQ'h(B*OJQJ^Jph hoh($hQ'h(5B*OJQJ^Jph%hRfyh(B*CJOJQJ^Jph%hoh(B*CJOJQJ^Jph(hoh(5B*CJOJQJ^Jph$hoh(5B*OJQJ^Jph)hhoB*CJOJQJ^JaJphkd,$$Iflֈ ,f!*R F6 t0644 lap<ytQ'd$IfgdQ'l kd-$$Iflֈ ,f!*R F6 t0644 lap<ytQ' d$IfgdQ'l   kd.$$Iflֈ ,f!*R F6 t0644 lap<ytQ'     d$IfgdQ'l   kd/$$Iflֈ ,f!*R F6 t0644 lap<ytQ'       d$IfgdQ'l   kd0$$Iflֈ ,f!*R F6 t0644 lap<ytQ' " $ & ( * d$IfgdQ'l * , kd1$$Iflֈ ,f!*R F6 t0644 lap<ytQ', . 0 2 4 6 8 d$IfgdQ'l 8 : kd2$$Iflֈ ,f!*R F6 t0644 lap<ytQ': < > @ B D F d$IfgdQ'l F H kd3$$Iflֈ ,f!*R F6 t0644 lap<ytQ'H J T!Z"\""$$%%%%X&b&x&&&$$Ifa$gdQ'l dgdZldgdoJ t "!$!(!*!>!@!B!L!N!R!!!!!!!񥻍nXnB/$jhyvB*OJQJU^Jph*j5hyvB*OJQJU^Jph*jhR;hVB*OJQJU^Jph!hR;hoB*OJQJ^JphheB*OJQJ^Jph/jhoB*OJQJU^JmHnHphu*j4hVB*OJQJU^Jph$jhVB*OJQJU^Jphh(B*CJOJQJ^Jph%hohoB*CJOJQJ^JphhoB*OJQJ^Jph!!!!!!!!!!!!"""$"&"("*"J"T"X"Z"\"""ٲَxَjUjB$jhVB*OJQJU^Jph)hhoB*CJOJQJ^JaJphhoB*OJQJ^Jph*j6hyvB*OJQJU^Jph!hR;hB*OJQJ^Jph$jhyvB*OJQJU^Jph*j5hyvB*OJQJU^Jph!hR;h(B*OJQJ^Jph!hR;hoB*OJQJ^Jph*jhR;hVB*OJQJU^Jph"""""""""####4#6#R#T#V#X#t#v######ȰȢyȢȢcyȢȢMyȢ*j7hyvB*OJQJU^Jph*jd7hyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*j6hyvB*OJQJU^JphhB*OJQJ^Jph/jhoB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jx6hVB*OJQJU^JphhoB*OJQJ^Jph#########$$ $$$$$6$:$<$X$Z$\$^$ȵއybOyy9*j>9hyvB*OJQJU^Jph$h;RhZl5B*OJQJ^Jph,h~h~5B*CJOJQJ^JaJphhZlB*OJQJ^Jph/jh(B*OJQJU^JmHnHphu*j8hVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jP8hyvB*OJQJU^Jph$jhVB*OJQJU^Jphh(B*OJQJ^Jph^$`$f$l$n$$$$$$$$$$$$$$$$%%%xjT</jhA|B*OJQJU^JmHnHphu*j*:hVB*OJQJU^JphhA|B*OJQJ^JphheB*OJQJ^Jph%h&h&B*OJQJ^JaJphh&B*OJQJ^Jph$jhyvB*OJQJU^Jph*j9hyvB*OJQJU^Jph$jhVB*OJQJU^Jphh(B*OJQJ^JphhZlB*OJQJ^Jph%% %$%&%B%D%F%H%Z%\%x%z%|%~%%%%%%%%%ȵȟȵvhhR:/jh(B*OJQJU^JmHnHphu*j;hVB*OJQJU^Jphh(B*OJQJ^Jph*j;hyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*j:hyvB*OJQJU^Jph$jhVB*OJQJU^JphhZlB*OJQJ^Jph$h;RhZl5B*OJQJ^Jph,h~h~5B*CJOJQJ^JaJph%%%%%% &&&&X&&&&&&&񠍶zsbQb;*jhQ'hVB*OJQJU^Jph!hQ'h `B*OJQJ^Jph!hQ'h$JB*OJQJ^Jph h$Jh$J$hQ'h$J5B*OJQJ^Jph$jhyvB*OJQJU^Jph*j<hyvB*OJQJU^Jph$jhVB*OJQJU^Jph$h$JhZl5B*OJQJ^Jph)hhZlB*CJOJQJ^JaJphhZlB*OJQJ^Jph&&&&H5"$Ifgdl $Ifgd `l kdx<$$Ifl\V *    t0644 lap(ytQ'&&&&&&&&&&''' '"'$'&':'<'P'R'T'^'`'v'x''տieL0j>hQ'hVB*OJQJU^Jphh$J0j=hQ'hVB*OJQJU^Jph!hQ'h `B*OJQJ^Jph!hQ'h$JB*OJQJ^Jph5jhQ'h(B*OJQJU^JmHnHphu*jhQ'hVB*OJQJU^Jph0j=hQ'hVB*OJQJU^Jph!hQ'h(B*OJQJ^Jph&&$'&'"kd>$$Ifl\V *    t0644 lap(ytQ'$Ifgdl $Ifgd `l &':'b'v''''5kd?$$Ifl\V *    t0644 lap(ytQ'$Ifgdl ''''''''''''''''((( ("($(&(2(4(H(J(ѶѥѐwѶѥѐ^ѶѥѐE0jAhQ'hVB*OJQJU^Jph0j@hQ'hVB*OJQJU^Jph0j0@hQ'hVB*OJQJU^Jph!hQ'h(B*OJQJ^Jphh$J!hQ'h$JB*OJQJ^Jph5jhQ'h(B*OJQJU^JmHnHphu*jhQ'hVB*OJQJU^Jph0j?hQ'hVB*OJQJU^Jph'''$(&(2(Z(5kdA$$Ifl\V *    t0644 lap(ytQ'$Ifgdl J(L(V(X(f(h(|(~((((((((((((((L)N)P)d)f)h)r)t)v)x))))ꭔ꾐w꾭^꾐0jChQ'hVB*OJQJU^Jph0jHChQ'hVB*OJQJU^Jphh$J0j2BhQ'hVB*OJQJU^Jph!hQ'h(B*OJQJ^Jph!hQ'h$JB*OJQJ^Jph5jhQ'h(B*OJQJU^JmHnHphu*jhQ'hVB*OJQJU^Jph!Z(f(((v)5kdB$$Ifl\V *    t0644 lap(ytQ'$Ifgdl v)x)))))}}}}$Ifgdl nkd4D$$Ifl*+ t0644 lap ytQ'))))))))))))))***&*(***4*6**$+&+(+<+Ѷѥє{Ѷѥwє^Ѷєє0jBFhQ'hVB*OJQJU^Jphh$J0j,EhQ'hVB*OJQJU^Jph!hQ'h(B*OJQJ^Jph!hQ'h$JB*OJQJ^Jph5jhQ'h(B*OJQJU^JmHnHphu*jhQ'hVB*OJQJU^Jph0jDhQ'hVB*OJQJU^Jph)*N+H5$Ifgdl kdE$$Ifl\V *    t0644 lap(ytQ'<+>+@+J+L+N+P+R+T+\+`+b+~++Ѷѥ|i[H[2*jGhyvB*OJQJU^Jph$jhVB*OJQJU^Jphh$JB*OJQJ^Jph$h;Rh$J5B*OJQJ^Jphh@ho5B*OJQJ^Jph)hhZlB*CJOJQJ^JaJphh$J!hQ'h$JB*OJQJ^Jph5jhQ'h(B*OJQJU^JmHnHphu*jhQ'hVB*OJQJU^Jph0jFhQ'hVB*OJQJU^Jph N+P+R+T++,\-^-.|/dgd;Rdgdonkd.G$$Ifl*+ t0644 lap ytQ'+++++++++++,b,v,x,,,,,,,,,,,,,2-4-6-J-̹̣̹̍u_̹*jIhyvB*OJQJU^Jph/jh$JB*OJQJU^JmHnHphu*jHhVB*OJQJU^Jph*j&HhyvB*OJQJU^Jph%h;Rh$JB*CJOJQJ^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^JphJ-L-N-X-Z-\-^------------ .׿ױiVC%h;Rh$JB*CJOJQJ^Jph$jhyvB*OJQJU^Jph*jIhyvB*OJQJU^Jphh$JB*OJQJ^Jph$h;Rh$J5B*OJQJ^Jph!hA|hA|B*OJQJ^Jphh~B*OJQJ^Jph/jh$JB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jIhVB*OJQJU^Jph ....".<.@.B.^.`.b.d.v.............. //*/,/ĶĶĶĶwĶĶaĶĶK*jLLhyvB*OJQJU^Jph*jKhyvB*OJQJU^Jph*j`KhyvB*OJQJU^Jph*jJhyvB*OJQJU^Jph%h;Rh$JB*CJOJQJ^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jtJhyvB*OJQJU^Jph,/./0/>/N/T/V/j/l/n/x/z/~//////////0 &(D̹̣ڋu̹s]*jMhyvB*OJQJU^JphU*j8MhyvB*OJQJU^Jph/jh$JB*OJQJU^JmHnHphu*jLhVB*OJQJU^Jph%h;Rh$JB*CJOJQJ^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^JphBOX  Nectar  FORMCHECKBOX  Honey  FORMCHECKBOX  Pudding Consistency considerations for medications:  FORMTEXT       Other information/concerns about nutritional status, eating habits, weight, support needs:  FORMTEXT       Swallowing Risks: (specify all that apply) Eating:  FORMCHECKBOX  Rapid eating  FORMCHECKBOX  Gorging/stuffing food  FORMCHECKBOX  Recurrent refusal of food/liquids/meds  FORMCHECKBOX  Loss of food/liquid from mouth while eating  FORMCHECKBOX  Motor/sensory concerns Chewing:  FORMCHECKBOX  Difficulty chewing  FORMCHECKBOX  Absent/no chewing  FORMCHECKBOX  No teeth or few teeth Swallowing:  FORMCHECKBOX  Choking  FORMCHECKBOX  Coughing during or after meals  FORMCHECKBOX  Gagging on food/liquid  FORMCHECKBOX  Difficulty swallowing  FORMCHECKBOX  Excessive throat clearing when eating or drinking Behavior:  FORMCHECKBOX  Agitation  FORMCHECKBOX Lethargy  FORMCHECKBOX  Inattention  FORMCHECKBOX  Distractibility  FORMCHECKBOX  Vocalizations during meals  FORMCHECKBOX  PICA  FORMCHECKBOX  Other (specify):  FORMTEXT        FORMCHECKBOX  None of the risks specified above have been observed/reported for this individual.  FORMCHECKBOX  Dining guidelines:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Check here if attached Current Health Care Providers: Primary:  FORMTEXT       Phone:  FORMTEXT       Address:  FORMTEXT       Last seen:  FORMTEXT       Others: Include Dentist, Neurologist, Psychiatrist, Psychologist, Podiatrist, etc. (specify name, address, phone, and date last seen and frequency of review/follow-up visits). Health SpecialtyAddressPhoneDate Last SeenF/U VisitPrimaryDentalVisionPharmacyVNAOther III. Vital Baseline or Receiving Nurse Assessment Vital Signs Date:  FORMTEXT       B/P:  FORMTEXT       T:  FORMTEXT       P:  FORMTEXT       R:  FORMTEXT       Ht:  FORMTEXT       Wt:  FORMTEXT       Ideal Body Weight/BMI:  FORMTEXT        FORMCHECKBOX  Not determined IV. Health Skills Assessment Requires assistance to understand medical treatments (if  yes specify all who assist):  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Staff  FORMCHECKBOX  Nurse  FORMCHECKBOX  Family  FORMCHECKBOX  Guardian  FORMCHECKBOX  PCP  FORMCHECKBOX  Other: Attends medical appointments independently (if  no specify type of assistance needed):  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Transportation  FORMCHECKBOX  Staff to accompany  FORMCHECKBOX  Other:  FORMTEXT       IV. ADL Skills: (Specify level of assistance needed)  Independent Needs PromptsNeeds SupervisionNeeds Physical AssistanceNeeds Total AssistanceBathingGroomingShavingDressingEatingTooth brushingToiletingAmbulatingTransfersMeal prepShoppingOther V. Recommended Health Follow-Up Conditions to be MonitoredFollow Up NeededAppointments Due/Scheduled ____________________________________ ______________ ________________________________ Signature of RN Completing Assessment Date Region/Agency If this form is used for the transfer of information, complete below and retain copy at previous placement __________________________________________________________________________________ Signature of Receiving RN Date Region/Agency Distribution: Individual s file, Evaluating RN, Case Manager     DEPARTMENT OF DEVELOPMENTAL SERVICES NURSING HEALTH AND SAFETY ASSESSMENT Name: DDS#: DOB: Community Health & Safety Assessment  Attachment A Page  PAGE 5 of  NUMPAGES 5 DEPARTMENT OF DEVELOPMENTAL SERVICES NURSING HEALTH AND SAFETY ASSESSMENT Name: DDS#: DOB: Community Health & Safety Assessment  Attachment A Page  PAGE \* MERGEFORMAT 1 DFHJ`b~ ĶĶĶ}ĶgOĶ?}h85B*OJQJ^Jph/jh$JB*OJQJU^JmHnHphu*jOhVB*OJQJU^Jph$h;Rh$J5B*OJQJ^JphhA|5B*OJQJ^Jph*jNhyvB*OJQJU^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*j$NhyvB*OJQJU^JphLNP\`b~ȰȢ|kT>*jOhyvB*OJQJU^Jph,h@hoh@ho5B*CJ OJQJ^JaJ ph!h@hoh$JB*OJQJ^Jph%h;Rh$JB*CJOJQJ^Jph$h;Rh$J5B*OJQJ^Jphh@hoB*OJQJ^Jph/jh$JB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jOhVB*OJQJU^Jphh$JB*OJQJ^JphNPvLVlTVRlp.8HTr$d$Ifa$gdQ'l dgdodgd;R "$&z|LZ^`|̶̠̊ta$h;Rh$J5B*OJQJ^Jph*jQhyvB*OJQJU^Jph*j^QhyvB*OJQJU^Jph*jPhyvB*OJQJU^Jph*jrPhyvB*OJQJU^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph|~"$&(VjnpĶĶĶĶĶwĶaĶĶK*j"ThyvB*OJQJU^Jph*jShyvB*OJQJU^Jph$h;Rh$J5B*OJQJ^Jph*j6ShyvB*OJQJU^Jph*jRhyvB*OJQJU^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jJRhyvB*OJQJU^Jph68:<prTVfjlȵyfP*jUhyvB*OJQJU^Jph$h;Rh$J5B*OJQJ^Jphh@ho5B*OJQJ^Jph*jUhyvB*OJQJU^Jph*jUhyvB*OJQJU^Jph$jhyvB*OJQJU^Jph*jThyvB*OJQJU^Jph$jhVB*OJQJU^Jphh$JB*OJQJ^Jph 02NPRT~4ĶĶĶĶĶĶtĶĶ^ĶĶ*jHXhyvB*OJQJU^Jph*jWhyvB*OJQJU^Jph*j\WhyvB*OJQJU^Jph*jVhyvB*OJQJU^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jpVhyvB*OJQJU^Jph468:H^`tvxRTprtvĶĶuĶĶ_ĶĶIĶ*j ZhyvB*OJQJU^Jph*jYhyvB*OJQJU^Jph/jh$JB*OJQJU^JmHnHphu*j4YhVB*OJQJU^Jph%h;Rh$JB*CJOJQJ^Jphh$JB*OJQJ^Jph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph*jXhyvB*OJQJU^Jph0246dj¯xe؞O؞AhB*OJQJ^Jph*j[hyvB*OJQJU^Jph%h `hB*CJOJQJ^Jphh `B*CJOJQJ^Jph*j [hyvB*OJQJU^Jph!h `hB*OJQJ^Jph$jhyvB*OJQJU^Jph*jZhyvB*OJQJU^Jph*jh `hVB*OJQJU^Jph!h `h$JB*OJQJ^Jphjlnpİ{h{Rh:h{h{/jh;RB*OJQJU^JmHnHphu*j[hVB*OJQJU^Jph$jhVB*OJQJU^Jphh;RB*OJQJ^Jph$h;Rh;R5B*OJQJ^Jph'hh;R5>*B*OJQJ^Jph'h;Rh;R5>*B*OJQJ^Jph/h@hoh~5>*B*CJ OJQJ^JaJ ph)hh;RB*CJOJQJ^JaJphh$JB*OJQJ^Jph *,.<@BVXZdf\6׿ױױ׿ױױr׿ױ_L$hQ'h@ho5B*OJQJ^Jph%h;Rh;RB*CJOJQJ^Jph*jZ]hVB*OJQJU^Jph*j\hVB*OJQJU^Jph$h;Rh;R5B*OJQJ^Jphh;RB*OJQJ^Jph/jh;RB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jn\hVB*OJQJU^Jph68FHRTpr ",.8:DF±ƒrnrnrnrnrnhe!hQ'heB*OJQJ^JphhAh;R!hQ'h;RB*OJQJ^Jph!hQ'h `B*OJQJ^Jphh(!hQ'h(B*OJQJ^Jph!hQ'hAB*OJQJ^Jph h(h;R$hQ'h(5B*OJQJ^Jph$hQ'h;R5B*OJQJ^Jph#0 d$IfgdQ'l kd]$$Iflr/e"* t0644 lap2ytQ'd$IfgdQ'l 0 d$IfgdQ'l kd^$$Iflr/e"* t0644 lap2ytQ'd$IfgdQ'l 0d$IfgdQ'l kd@_$$Iflr/e"* t0644 lap2ytQ'd$IfgdQ'l 0d$IfgdQ'l kd_$$Iflr/e"* t0644 lap2ytQ'd$IfgdQ'l 0d$IfgdQ'l kd`$$Iflr/e"* t0644 lap2ytQ'd$IfgdQ'l  0d$IfgdQ'l kdha$$Iflr/e"* t0644 lap2ytQ' d$IfgdQ'l 0d$IfgdQ'l kd b$$Iflr/e"* t0644 lap2ytQ' d$IfgdQ'l  "$0d$IfgdQ'l kdb$$Iflr/e"* t0644 lap2ytQ'$&(*,d$IfgdQ'l ,.00d$IfgdQ'l kdc$$Iflr/e"* t0644 lap2ytQ'02468d$IfgdQ'l 8:<0d$IfgdQ'l kdHd$$Iflr/e"* t0644 lap2ytQ'<>@BDd$IfgdQ'l DFH0((dgd:kde$$Iflr/e"* t0644 lap2ytQ'FHR&(02Fӿu]G]*j.fhVB*OJQJU^Jph/jhB*OJQJU^JmHnHphu*jehVB*OJQJU^Jph$jhVB*OJQJU^JphhB*OJQJ^Jph$h:h5B*OJQJ^Jph'h:h5>*B*OJQJ^Jph'h:h:5>*B*OJQJ^Jph/h~h~5>*B*CJ OJQJ^JaJ phL\RTVXZdgdo)d$d%d&d'dNOPQgd,$d$d%d&d'dNOPQa$gd:FHJTV^`tvx׿ױױ׿ױױ׿ױpױZ׿ױױ*jhhVB*OJQJU^Jph)hhB*CJOJQJ^JaJph*jghVB*OJQJU^Jph*jghVB*OJQJU^JphhB*OJQJ^Jph/jhB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*jfhVB*OJQJU^Jph :BFH\^`jlpr׿ױױ׿ױױwdױVA)hhB*CJOJQJ^JaJphhoB*OJQJ^Jph$jhyvB*OJQJU^Jph*jhihyvB*OJQJU^Jph*jhhVB*OJQJU^Jphh(B*OJQJ^JphhB*OJQJ^Jph/jhB*OJQJU^JmHnHphu$jhVB*OJQJU^Jph*j|hhVB*OJQJU^Jph^®xhSh;&Sh(jhyvB*CJOJQJU^Jph.jihyvB*CJOJQJU^Jph(jhVB*CJOJQJU^Jphh~B*CJOJQJ^Jph%h:h:B*CJOJQJ^Jphh:B*OJQJ^Jph)hh:B*CJOJQJ^JaJph'h:h5>*B*OJQJ^Jph'h:h:5>*B*OJQJ^Jph!h:5>*B*OJQJ^Jph/h~h~5>*B*CJ OJQJ^JaJ ph &(*,:<XZ\^lnî۞yaLyy4Ly.jDkhyvB*OJQJU^JaJph(jhyvB*OJQJU^JaJph.jjhyvB*OJQJU^JaJphh:B*OJQJ^JaJph(jhVB*OJQJU^JaJphh:B*CJOJQJ^Jph(jhyvB*CJOJQJU^Jph.jVjhyvB*CJOJQJU^Jphh~B*CJOJQJ^Jph(jhVB*CJOJQJU^Jphn­­ubT>*jlhyvB*OJQJU^Jphh&B*OJQJ^Jph$jhVB*OJQJU^JphheB*OJQJ^JaJphhB*OJQJ^JaJph.j2lhyvB*OJQJU^JaJph(jhVB*OJQJU^JaJph(jhyvB*OJQJU^JaJph.jkhyvB*OJQJU^JaJphh:B*OJQJ^JaJph 68:<>HJLʷ{jT{j?/h:B*OJQJ^JaJph)hh:B*CJOJQJ^JaJph*j mhyvB*OJQJU^Jph!hR;h&B*OJQJ^Jph*jhR;hVB*OJQJU^Jph%hR;h&B*OJQJ^JaJph%hR;hB*OJQJ^JaJph%hR;heB*OJQJ^JaJphheB*OJQJ^JaJph$jhVB*OJQJU^Jph$jhyvB*OJQJU^Jph 02NPRTZ\^z|ܯ܂r]rE.jnhyvB*OJQJU^JaJph(jhVB*OJQJU^JaJphh:B*OJQJ^JaJph.jnhyvB*CJOJQJU^Jph(jhyvB*CJOJQJU^Jph.jmhyvB*CJOJQJU^Jph(jhVB*CJOJQJU^Jphh~B*CJOJQJ^Jph%h:h:B*CJOJQJ^Jph|~*,@BDNPRTƮƞƆnT?)hh:B*CJOJQJ^JaJph3jh:B*OJQJU^JaJmHnHphu.johVB*OJQJU^JaJph.jvohyvB*OJQJU^JaJphh&B*OJQJ^JaJph.jnhyvB*OJQJU^JaJphh:B*OJQJ^JaJph(jhVB*OJQJU^JaJph(jhyvB*OJQJU^JaJphTVXZbv>@^`Ƴun[W[W[W[W[W[W[W[W[W[W[W[Wh:%hQ'h:B*OJQJ^JaJph h &h:(hQ'h:5B*OJQJ^JaJph%h:h:B*CJOJQJ^Jph+h:h:5>*B*OJQJ^JaJph%h:5>*B*OJQJ^JaJph%hf5>*B*OJQJ^JaJph%h85>*B*OJQJ^JaJph%h~5>*B*OJQJ^JaJph $X$$Ifa$gdQ'l kddp$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdq$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdq$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdr$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kd8s$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ' $Ifgd &l kds$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'468:<>$Ifgd &l >@kdt$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'@TVXZ\^$Ifgd &l ^`kdTu$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'`vxz|~$Ifgd &l kdv$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdv$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdpw$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kd$x$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'$Ifgd &l kdx$$Iflֈ Dp#*,,,,,, t0644 lap<ytQ'<>t$$Ifa$gdQ'l dgdo(:<>Ҿubu[JFJFJFJF5!hQ'hAB*OJQJ^Jphh:!hQ'h:B*OJQJ^Jph hR;h:$hQ'h5B*OJQJ^Jph$hQ'h:5B*OJQJ^Jph'h:hA|5>*B*OJQJ^Jph!h@ho5>*B*OJQJ^Jph!h:5>*B*OJQJ^Jph'h:h:5>*B*OJQJ^Jph/h~h~5>*B*CJ OJQJ^JaJ ph)hh:B*CJOJQJ^JaJph`MMM$Ifgd &l kdy$$IflF D*XXX t06    44 lapytQ'`MMM$Ifgd &l kd"z$$IflF D*XXX t06    44 lapytQ'`MMM$Ifgd &l kdz$$IflF D*XXX t06    44 lapytQ'`MMM$Ifgd &l kdN{$$IflF D*XXX t06    44 lapytQ'`MMM$Ifgd &l kd{$$IflF D*XXX t06    44 lapytQ'`MMM$Ifgd &l kdz|$$IflF D*XXX t06    44 lapytQ' bt,@\ȺrbrO?O?O?Oh &B*CJOJQJ^Jph%h &h &B*CJOJQJ^Jphh~B*OJQJ^JaJphh &B*OJQJ^JaJph)h &h &B*CJ OJQJ^JaJ ph)h &h &B*CJOJQJ^JaJphh &B*OJQJ^JphhA|B*OJQJ^Jphh~B*OJQJ^Jphh~!hQ'h~B*OJQJ^Jph!hQ'hAB*OJQJ^JphhA`MMM$Ifgd &l kd}$$IflF D*XXX t06    44 lapytQ' `MMM$Ifgd &l kd}$$IflF D*XXX t06    44 lapytQ' `MMM$Ifgd &l kd<~$$IflF D*XXX t06    44 lapytQ'`XXXXXXdgdokd~$$IflF D*XXX t06    44 lapytQ'b`bdfhjlgdUTldgd8dgd~)d$d%d&d'dNOPQgd~\^blPT0:xz|~͸͔ld`d`d`d`UMUMUMUI`hMhMB*phhUTlhMB*phhyvjhyvU%h &hAB*CJOJQJ^Jph)h~h~B*CJOJQJ^JaJph#h~B*CJOJQJ^JaJph#h8B*CJOJQJ^JaJph)h~h8B*CJOJQJ^JaJph#h@hoB*CJOJQJ^JaJphh~B*CJOJQJ^JphhAB*CJOJQJ^JphTz|~DFHdfhjldgd~ H$0*$d Nb$# gdQ'gdUTl$a$gdUTlgdRfy$a$gdRfygdUTl~ $&<>@BDFHPnx ",.\^ϯϯ擏||qi^VRVhObjhObUhQ'hMOJQJhQ'OJQJhQ'hfOJQJhMB*phhUTlhMB*phhyvhM/jhfhM5CJOJQJU^JaJ*#hQ'5OJQJ^JmHnHu*hfhM5OJQJ^J,jhfhM5CJOJQJU^JaJhfhMOJQJ^JhfhfOJQJ^J^`bdfjlŲ%h &hAB*CJOJQJ^JphhyvhMhQ'hMOJQJ+jhQ'hObOJQJUmHnHu*"hQ'hQ'OJQJmHnHu*9 0&P1:p~/ =!"#$% tDText1tDText2tDText3tDText4tDText5$$If!vh#v#vZ:V l  t0655ZpytQ'tDeCheck1tDeCheck2$$If!vh#v#vZ:V l t0655ZpytQ'tDeCheck3tDeCheck4$$If!vh#v#vZ:V l t0655ZpytQ'tDeCheck5tDeCheck6$$If!vh#v#vZ:V l t0655ZpytQ'tDeCheck7tDeCheck8tDeCheck9$$If!vh#v#vZ:V l t0655ZpytQ'vDeCheck10vDeCheck11$$If!vh#v#vZ:V l t0655ZpytQ'vDeCheck12xDeCheck109$$If!vh#v:V l  t 065pytQ'vDeCheck13vDeCheck14vDeCheck15$$If!vh#v#v #vX:V l t0655 5XpytQ'vDeCheck16vDeCheck17vDeCheck18$$If!vh#v#v #vX:V l t0655 5XpytQ'xDeCheck105xDeCheck106xDeCheck107xDeCheck108tDText6tDText7tDText8tDText9vDText10xDeCheck110xDeCheck111xDeCheck112vDText66tDText6tDText7tDText8tDText9vDText10vDText11vDText12vDText13vDeCheck19vDText14vDeCheck20vDText15vDeCheck21vDText16vDText17vDText18vDeCheck22vDText19vDText20vDeCheck23vDeCheck24vDeCheck25vDeCheck26vDeCheck27vDeCheck28vDText21vDeCheck29vDeCheck30vDeCheck31vDText22vDeCheck32vDeCheck33xDeCheck119vDText23vDText29vDeCheck36vDeCheck37vDeCheck38vDText30vDText31vDeCheck39vDText32vDeCheck40vDeCheck41vDeCheck42vDText37vDText38vDeCheck43$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'$$If!vh#vR #vF#v#v#v#v6 :V l t065R 5F55556 p<ytQ'vDText39vDeCheck44vDeCheck45vDeCheck41vDText41vDeCheck94vDeCheck95vDeCheck96xDeCheck114vDText67vDeCheck46vDeCheck47vDText83vDeCheck54vDeCheck55vDText68vDeCheck56$$If!vh#v :V l t065 p(ytQ'vDText69vDText70$$If!vh#v :V l t065 p(ytQ'vDText71vDText72$$If!vh#v :V l t065 p(ytQ'vDText73vDText74$$If!vh#v :V l t065 p(ytQ'vDText75vDText76$$If!vh#v :V l t065 p(ytQ'vDText77vDText78$$If!vh#v+:V l t065+p ytQ'vDText79vDText80$$If!vh#v :V l t065 p(ytQ'vDText81vDText82$$If!vh#v+:V l t065+p ytQ'vDeCheck57vDeCheck58vDText44vDeCheck59vDText46vDeCheck60vDeCheck61vDeCheck62vDeCheck63vDeCheck64vDeCheck65vDText50vDeCheck66vDeCheck67vDeCheck68vDeCheck69vDText51vDText47vDeCheck70vDeCheck71vDeCheck72vDeCheck73vDeCheck74vDeCheck75vDeCheck76vDeCheck77vDeCheck78vDeCheck79vDeCheck80vDeCheck81vDeCheck82vDeCheck83vDeCheck84vDeCheck85vDeCheck86vDeCheck87vDeCheck88vDeCheck89vDText52vDeCheck90vDeCheck91vDeCheck92vDeCheck93vDeCheck89vDText53vDText54vDText55vDText56$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'$$If!vh#v#v:V l t0655p2ytQ'vDText57vDText58vDText59vDText60vDText61vDText62vDText63vDText64vDeCheck97xDeCheck115xDeCheck116vDeCheck98vDeCheck99xDeCheck100xDeCheck101vDeCheck89vDeCheck89xDeCheck117xDeCheck118xDeCheck102xDeCheck103xDeCheck104vDText65$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#v,:V l t065,p<ytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'$$If!vh#vX:V l t065XpytQ'^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH P`P zNormal(B* CJOJQJ]_HmH phsH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List 4@4 UTl0Header H$FoF UTl0 Header CharB* CJOJQJ]ph4 @4 UTl0Footer H$Fo!F UTl0 Footer CharB* CJOJQJ]phj`3j E Table Grid7:V0H@BH M0 Balloon TextCJOJQJ^JaJZoQZ M0Balloon Text Char B* CJOJQJ]^JaJphPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] L' ,<? F Z r  206PJ(J !"#^$%%&'J()<++J- .,/D|4j6FFn|T\~^l #&()+,-./012345689:;<MNOPQRSUXZ]_abcdwxz{|}~ ^ Z s       * , 8 : F H &&&''Z(v))N+  $,08<D>@^` l!"$%'*7=>?@ABCDEFGHIJKLTVWY[\^`y ;GM_kq )9:Rbcn~ 7GH_op}-.=MN[kl%56Rbc /0JZ[m}~$06Uagy EQWYij~ *6<p  $ 4 5 O [ a v  ' ( 1 A B z   ) 9 : C S T \ h n }  " # K [ \ { *6<gwx~!"0@AP`at(89CSTeqw &3?EQ]cx=IOeqw)5;FVWt0<Bbrs,-@LRUef ~'(Scd()M]^l|}  K[\l|}!12EQWYij/0v~ 9EKN^_*+3CDL\]fvw $ % . > ? D T U f v w L'FFFFFGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTFFFFFGTGTGTFFFFFFFFFGTFGTFGTFFFGTFFGTGTGTGTGTGTFGTGTGTFGTGTGTFFGTGTGTFFGTFGTGTGTFFGTFGTGTGTFGTGTGTGTFGTGTFGTGTFGTFFFFFFFFFFFFFFGTGTFGTFGTGTGTGTGTGTFGTGTGTGTFFGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTGTFGTGTGTGTGTFFFFFFFFFFFFGTGTGTGTGTGTGTGTGTGTGTGTGTGTF &(68?!!T # @H 0(  0(  B S  ?Text1Text2Text3Text4Text5Check1Check2Check3Check4Check5Check6Check7Check8Check9Check10Check11Check12Check109Check13Check14Check15Check16Check17Check18Check105Check106Check107Check108Text6Text7Text8Text9Text10Check110Check111Check112Text66Text11Text12Text13Check19Text14Check20Text15Check21Text16Text17Text18Check22Text19Text20Check23Check24Check25Check26Check27Check28Text21Check29Check30Check31Text22Check32Check33Check119Text23Text29Check36Check37Check38Text30Text31Check39Text32Check40Check41Check42Text37Text38Check43Text39Check44Check45Text41Check94Check95Check96Check114Text67Check46Check47Text83Check54Check55Text68Check56Text69Text70Text71Text72Text73Text74Text75Text76Text77Text78Text79Text80Text81Text82Check57Check58Text44Check59Text46Check60Check61Check62Check63Check64Check65Text50Check66Check67Check68Check69Text51Text47Check70Check71Check72Check73Check74Check75Check76Check77Check78Check79Check80Check81Check82Check83Check84Check85Check86Check87Check88Check89Text52Check90Check91Check92Check93Text53Text54Text55Text56Text57Text58Text59Text60Text61Text62Text63Text64Check97Check115Check116Check98Check99Check100Check101Check117Check118Check102Check103Check104Text65 <` *So8`~>\&S  KnVzFZ +q% P w  2 { * D ] ~  L | +h1Qu)Df4Ry>f*Gu1cAVTNmLm"FZw:O4Mg / E g M'  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Nr;dIq/Om7d1\h  Xk= 6 b ) C  ; U o $ ] =y#Bb:Ux 'FdPx<XCt.Sg!)e*_~ ]~3Xk !L`,E^x& @ V x M' ov%%%%%%%%%%%7&7&&'''J'M'*3$ %%%%%%%%%%%7&7&&'''J'M' %%%%&$&(&7&7&&''','G'M'. '<N<ipq 6 ',T8FKMMT_ bj,lmud O#GU`shk~t&+:oDBOY[sstz  #F";I5<FV D>BOcRkox1[4@Wqu/ I7 > /P ] c K  & : X _ f + 8 < C D 8` d f  & FB qF 2M k l p wr p= E RH M u &01F!R]ef/$V[ $6,]?@f[rkuyZju-x<;VTZVa&+X7HQU_PwM'G)-=AJf TVBAOSv28QSSjzoo~ oV9?E%JONNt} R)$&Mf:kbk3rwgAAGlJLV^u0u u:R*d'sd4<A_JizQ{!}-0 g #2GEH)Yl'K/0RSd#<En[ `6`cm9psw4[ACir9ty_?^lF  VW Ga y ~ !o!!:!HN!.O!P!a!v!y!|!"g"D"e"C ###5?#V#vW#rv#v#"$"$ $$L%$'$D5$^H$I$J$PN$Q$i$xk$}m$p$zw$x$wy${$+|$%%r %7%u9%aN%q^%&&& #&'&UR&^&Q'F'''~$'7'qA'v'#(%(A(i(p( )m)m)O)O)MR)DS)j)_})**?*P*z+r+b!+[%+%+1+n@+U+}`+`+,l+w+E ,,E!,3,:,>,FG,G,j,-nG-e-|-.. .H.4.;.H.'i.Tz.@{./ /(/A/E/F/X/e/^g/~/I70O=0?0C0[0^0d0mw01 1S1} 1!1,@1D1e1P2222v232}2&2z*2^/2xC2C2E2IP2i2n2iy2G333X3q3J,343:3A3J3V3Y3@d3d3i3;n3t3}3c44L4gB4F4k4pr4]555{5V15,25=5xL5KT5Y5a5e5Lg5m5,o5|5666&6#6A/686:6@6[6^6|a6l6r6K77c 777 7"77ME79i7 }788 8-8E=8H8_8`8y8997.93Y9N`9Vg9r9c::>':x+:s1:T:S\:Ml:lr:D{:f~:.&;+; /;R;S;V[;<8<g<6p< =='=x.=1;=B=]=#^=`=h=p=x=j}=3>;>;\>^>un> z>V$?3?@?7C?kN?{?*?@%@C@!@)@l0@^1@R@j@" A9Aq4ALA6UA}[A9oA1BYBr_BnBxBC C"C{,CJCXoC<{C D D9#D}#D>D ?D:MD\\DnD*{DsEEtE"E+EME_PEREdEqnEF FF'F&2FOcFcFhFwF:zF*G?GeFGMGPG TG_GlG$H HHH[H`HncHkHII)IGIPIcIHrItI]J(JJ$J,*J6.J^BJcJlnJzJKKK$KLKLK1RK|WKwcK LpL8LM%LZN?NANsJNONWVKWdW~W6X XX2X#X-X.XZXoyXwYS Yi YI:YTY]Y\cY:ZZ4Z5ZXZiZsZsZOvZ+["[&[D[`G[O[P[ S[dT[`[eb[f[\%\\u3\Y\]]$]<]N])T]^]t]}]^&^:^B^)]^/ __&_>N_NO_O_AS_T_PZ_]_ox_9`%`e3`:`KC`Q`Wn` }`}`l aa'1aNaoaabbb 4b7b?b7@bDbEbFb[WbeZbCebvb wb-|b#/cCdTd"Ydxedmdudneeee!e;eGe]eue}eeffffFf9fT>f2Zf]f4mfyfv}f}f~fA g gg%g.g:AgBgVCgKgOghgHzg|ghYh;h7hc>h>hIh_bhfhqh(zh1i" i1 i7iX#i%i8i;iKDiH\ihidximj#j1jRj^jajfujvj3~jbkAkTk]kckekkklkl9lUTlWlZli\l.ulkm|m:mj*m4m 5s6s7sVSs[s}{3}=}:X}j}k}*~+~9~>~,I~e~4& I-N*j@129L|_JTc&=ySX Z)u6wB/ 3Tir v#$AFJYOPWn_hoqxk|ac'kuk p{14Zf-w"EYjl[xr#hhm3 vQ67Zc&)e7-B C'PWcc!x~;M!)+PLM[$uV(f!+4^>]I[r]trx%{lm '0ClCzR+ *]C!\pn 1!37;U[q-jE%k09;xP]jl5&[)vCVEEGI^c@rE8PcTz= Zo@-8FFJSevXg 7"%(:5DDUlcmm!D-4?/BBMhw -\34N@[lm~'(L+4MkuyyL0,=1:EoGWmT(->T`ux~8O",/UNRXf|P#@@kB^Zq"twd;&j<@kB3FEj&'),_5`P [iEl$.4L77:^<Hk ' 6:@?vI LOP"7Yyff=I_XhdiB(0Keri7rn !*<MU5XXYX^gafdjjtH?fA Zbdl (%mvo!+c qqIt!*J\fgrv z/a0:B;z^mr@|~$?6V*Ygiquv}P\ "a(0 5:KDxY xBP:T]cQlX0#7TxU_o p{o"p7@AwP\dj>v}i" B+/MT WWCeKf.slvu(^/067HL-M1^c4dwqKru CWj\$^islRmdo~K i !?^?AVacv .9A\E;Rd`+#Ljttw x(G\KK\bs 3GNOQ\%i_t (r*4G:R*WX[qsvx9 '2Tcx(ZR]y &12(7C:Gdaj+ U(s(D5[]d"n?oyzR$<@F'c6HU[\6_(#J)l:?p 8<_R_#bmmq(#%K25HI(J[qux.(/;O}fwy}* GNF]r-y2c4;GJKldB+IjHq(w"9*y35,H 1335)>SaKcn{ K#$(#+;GpI `~kF'(2NuSD]dd}w~8U^=~pvU 88LK /j0gACFM[m}' B4~8: DmMdi+&8+FI{Xb (7IN%2';GTlno;z!s$8%&/48AXd\ Q +/Vr{!65ACP^mczxz{ dE/i0a>D%IXZ|euwi~> pEJO_Qcx".0n1l6R\x Q%e+-d4IfU,Vpx c&U^d()13DNMDN?y%1{ m".49:_esh_b 4"&|'x0.EEEAZihQx[)!L<<=MSR~n,;BIJ.NV1fhz]{K&ePR^d{[ "7z>ZiVpWquw }6=O?RDoK5[gz',3X4AOWmA|k* &@699X0w0\5X\tx4.6N>>Q[`pu~K&`5Y:RmZn+w|{$ h YP ,\6S88f9@Q*_ SBgDIsNmS_=eMy1q3L]S ^bc~lZ357SWadqEz 0i!"0<IJQJX(ayuv$3u9O;?XZab~9w"1/8A=Xb]^\t&x A?ALnPHwwF|{ 6+?J-eh8i~j!vz%$.]8^am{8  7<.=dCR[Oc! IMmkB/kV{dew4E1d:m;=pEHTg``gi  )2U[ko% 7 l%)=EJf!mDuE{5X $]b* }'-YObakblpUq~}e \7TD"QTbgkI #7=>OkQq >HHPE L9 S0_zmdqF3.;Qnv{~k4-b254y5?IPi>>*%1$>G>UyY_{boEw%%@ L'@ "$&(*,.UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7@CambriaCNComic Sans MS5" TahomaACambria Math"1h]]gCC!d0$$BHX  $PUTl2!xx  valentineo bouchardjcOh+'0<x   $,4 valentineo41EE9CDE.dotm bouchardjc2Microsoft Office Word@@J@p@p՜.+,0 hp  State of ConnecticutC$  Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDFGHIJKLNOPQRSTYZ]Root Entry F \Data h1TableihWordDocument ;SummaryInformation(EDocumentSummaryInformation8MMsoDataStoreP誺 HJZK2CMOO2==2P誺 Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q