zilongwang/ReadingBank huggingface dataset:
Life Skills Week 1: March 4-8 Solving Problems among friends, page 38 No Homework No Test Week 2: March 11-15 Steps in Solving Problems, page 39 No Homework No Test Math Week 1: March 4 – 8 Lesson 7.4 Compare Numbers(TB page -302) Lesson 7.5 10 less, 10 more ( TB page -306 ) Chapter 7 Review Practice for Test Math Test No Homework Math Test on Thursday March 8 ,2018 The portion for the test are as follows -Chapter 7 Compare Numbers Lessons 7.1, 7.2, 7.3, 7.4 Week 2: March 11 - 15 Chapter 8 Two – Digit Addition and Subtraction Lesson 8.1 Add and Subtract within 20.( TB page -318) Lesson 8.2 Add Tens( TB page – 322) Lesson 8.3 Subtract Tens ( TB page -326 ) Lesson 8.5 Use Models to Add ( TB – 334 ) Home work will be given on Thursday . Homework: Practice Book Lessons 8.1,8.2,8.3 No Test Computer Week 1 March 4 – 8 11.3 The Text tool More Practice Week 2: March 11 – 15 11.7 Change the Color Pages(51) UCMAS Week 1: March 4-8 UCMAS Activities Small Friends: ( -1 = +4-5 ) H.W: (Book B) Don’t forget the UCMAS books and Abacus every class. Week 2: March 11-15 UCMAS Activities Mid-Term Exam H.W: Book B Mid-Term exams will be practical during the normal classes. (Book A) Pg.13-14-15-16 Don’t forget the UCMAS books and Abacus every class.
Lesson 9.2 Estimate lengths in Centimeters Lesson 9.3 Measure with a Centimeters Ruler Homework: Practice Book Lesson 7.9, Lesson 7.10, Lesson 7.11 Quiz Coverage : Lesson 7.9 Week 2: Mar 25-29 Lesson 9.4 Problem Solving Add and Subtract Lengths Lesson 9.5 Centimeters and Meters Lesson 9.6 Estimate Lengths in Meters Lesson 9.7 Measure and Compare Lengths Home work will be given on Thursday will be from Practice Workbook. The Homework must be submitted on the following Sunday: Homework: Practice Book: Lesson 8.3, Lesson 8.4, Lesson 8.5 No Test Life Skills Week 1: March 4-8 Unit 4: My Friends “My Friends” page 33 Please answer the observation checklist. This is an assessment if your child is applying what he/she learns from our lessons in Unit 3: Family. Bring 4 small pictures of what you love to do with your friends. No Test Week 2: March 11-15 Unit 4: My Friends My Friends page 34 No Homework No Test Computer Week 1: March 18 - 22 3. Introduction to Word Process: Typing Work sheet 2 Focus on Ribbon tools No Homework No Test Week 2: March 25 - 29 Typing Work sheet 3 Focus on Ribbon tools No Homework No Test UCMAS Week 1: march 18-22 Ucmas Activities. Mixed family -9=-4+5-10 Class work book B P23 H.W Book B p24 Don’t forget the UCMAS books and Abacus every class. Week 2: march 25-29 Ucmas Activities. Two digits No Homework Don’t forget the UCMAS books and Abacus every class.
Lesson 7.9 Time to 5 minutes Practice Review Homework: Practice Book Lesson 6.6, 6.9, 6.10, Lesson 6.6 Lesson 6.9 Lesson 6.10 Week 2: Mar 11- 15 Lesson 7.10 Practice Telling Time Lesson 7.11 A.M and P.M Lesson 7 Money Bahraini Dinar and Fils (Worksheet will be provided) Home work will be given on Thursday It will be from Practice Workbook. The Homework must be submitted on the following Sunday. Homework: Practice Book :Lesson 7.8 . Life Skills Week 1: March 4-8 Unit 4: My Friends “My Friends” page 33 Please answer the observation checklist. This is an assessment if your child is applying what he/she learns from our lessons in Unit 3: Family. Bring 4 small pictures of what you love to do with your friends. No Test Week 2: March 11-15 Unit 4: My Friends My Friends page 34 No Homework No Test Comp. Week 1: March 4 - 8 3. Introduction to Word Process: Typing Practice (Work sheet) No Test Week 2: March 11 – 15 Typing Work sheet No Test UCMAS Week 1: march 4-8 Ucmas Activities. Mixed family -8=+3-5+10 Class work book B P21 H.W Book B p22 Don’t forget the UCMAS books and Abacus every class. Week 2: march 11-15 Ucmas Activities. Mixed family -9=+4-5+10 Class work book B P23 H.W Book B P24 Don’t forget the UCMAS books and Abacus every class.
Are Title VI posters prominently displayed? Yes □ No□ Are they in areas where services are provided? Yes □ No□ Are Title VI posters or program brochures available in languages other than English? Yes □ No□ (If yes, please attach copies of documentation.) Contractors Documentation Is information about Title VI disseminated to your contractors, sub-contractors (Third Party Contracts) Yes □ No□ How? _________________________________________________________________________________________ ______________________________________________________________________________________________ Describe contracting opportunities afforded to socially and economically Disadvantaged Business Enterprises (DBEs). Do all sub/third party contracts contain a Title VI Statement of Compliance? Yes □ No□ (If yes, please attach copies of documentation.) Demographics Documentation Please provide the racial and ethnic demographics of your service area (this information can be obtained at ). Does your service population include ethnic groups representing a 5% safeguard or more of your total population? Yes □ No□ Executive Order 13166 Documentation Are you aware of your agency’s obligation to comply with Executive Order 13166 Limited English Proficiency (LEP)? Yes □ No□ Does your organization have a Limited English Proficiency (LEP) plan? Yes □ No□ How do you ensure persons with LEP can access your services? (Requires a written response) Complaints Documentation Does your organization have a written complaint and hearing system for discrimination complaints? Yes □ No□ (If yes, please attach documentation.)
Never installing unauthorized software on workstations. Securing laptops that contain sensitive information by using cable locks or locking laptops up in drawer or cabinets. Complying with the Laptop and portable Device Encryption Policy. Installing privacy screen filters or using other physical barriers to alleviate exposing data. Exit running applications and close open documents when leaving for extended periods of time. Ensuring that all workstations use a surge protector (not just a power strip) or a UPS (battery backup). Policy Compliance Compliance Measurement IT staff will verify compliance to this policy through various methods, including but not limited to, periodic walk-thru, automated monitoring, internal and external audits, and provide feedback to the workstation owner. Enforcement The Director of Computer Services is authorized to mitigate any non-compliance with this policy at any time either directly or through delegation to staff. Exceptions Any exception to the policy must be approved by the Director of Computer Services. Revision History Date: November 2014 Description: Original Policy Server Malware Protection Policy Purpose The purpose of this policy is to outline which server systems are required to have anti-virus and/or anti-spyware applications. Scope This policy applies to all servers connected to any Gadsden State Community College (GSCC) network. This explicitly includes any system for which the Information Technology (IT) department has the responsibility to administer. This also includes all server systems setup for use at any GSCC campus or facility, regardless of whether the IT department retains administrative obligation or not. Policy IT staff will adhere to this policy to determine which servers will have anti-virus and/or anti-spyware applications installed on them and to deploy such software and/or hardware appliances as appropriate. Anti-Virus All servers not explicitly exempted MUST have an anti-virus application installed that offers scanning protection to files and applications running on the target system if they meet one
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wis. Admin. Code §§ DHS 107.10(2), 152.06(3)(h), 153.06(3)(g), 154.06(3)(g) F-00030 (04/2017) FORWARDHEALTH STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST Instructions: The use of this form is mandatory to request the review of state Maximum Allowed Cost (MAC) pricing in the ForwardHealth drug index. Pharmacists are required to submit documentation to substantiate their actual acquisition cost (AAC) and sign the certifying statement below. The pharmacy must submit an invoice having a product date of purchase within 60 days of submitting the request. Refer to the State and Specialty Maximum Allowed Cost Drug Pricing Review Request Completion Instructions, F-00030A, for more information. Requests for pricing review will not be accepted for Wholesale Acquisition Cost, National Average Drug Acquisition Cost (NADAC), or ceiling price rates on file for a National Drug Code (NDC). National Average Drug Acquisition Cost review requests are submitted via the following: Telephone (toll-free): 855-457-5264 Email: Fax: 844-860-0236 The completed form may be returned to the Drug Authorization and Policy Override Center via fax at 608-250-0246 or by mail at the following address: ForwardHealth Drug Authorization and 313 Blettner Blvd Madison WI 53784 SECTION I – PHARMACY INFORMATION 1. Name – Pharmacy 2. National Provider Identifier 3. Taxonomy Code 4. ZIP+4 Code – Practice Location 5. Address – Provider (Street, City, State, ZIP Code) 6. Telephone Number – Provider 7. Fax Number – Provider 8. Name – Contact Person SECTION II – PRODUCT AND PRICE INFORMATION 9. NDC (11-Digit No.) 10. Drug Name 11. Current State or Specialty MAC Drug Rate – Per Unit Rate 12. Net Cost – Per Unit Rate* Continued STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST 2 of 2 F-00030 (04/2017) SECTION II – PRODUCT AND PRICE INFORMATION (Continued)
Has the participant/subject had any adverse events during the study? Yes No Table 1 Record diagnoses (if known) or signs/symptoms the participant/subject experienced during the study that qualify as adverse events Adverse Event(s) Date and Time of Onset Date of Resolution Severity Investigator Assessment of Causality Action Taken with Study Intervention Other Action Taken Outcomes Attributed to the Event Serious Adverse Event? Adverse Event? IRB Notified SAE Form Data to be fillen in by site Not resolved Mild Moderate Severe Life-threatening Fatal/Death Unrelated Unlikely Reasonable Possibility Definite None Study Intervention Interrupted Study Intervention Discontinued Study Intervention Modified None Non-Study Treatment Required Recovered/Resolved Recovered/Resolved With Sequelae Recovering/Resolving Not Recovered/Not Resolved Fatal Unknown No Yes No Yes No Yes No Yes Data to be fillen in by site Not resolved Mild Moderate Severe Life-threatening Fatal/Death Unrelated Unlikely Reasonable Possibility Definite None Study Intervention Interrupted Study Intervention Discontinued Study Intervention Modified None Non-Study Treatment Required Recovered/Resolved Recovered/Resolved With Sequelae Recovering/Resolving Not Recovered/Not Resolved Fatal Unknown No Yes No Yes No Yes No Yes Data to be fillen in by site Not resolved Mild Moderate Severe Life-threatening Fatal/Death Unrelated Unlikely Reasonable Possibility Definite None Study Intervention Interrupted Study Intervention Discontinued Study Intervention Modified None Non-Study Treatment Required Recovered/Resolved Recovered/Resolved With Sequelae Recovering/Resolving Not Recovered/Not Resolved Fatal Unknown No Yes No Yes No Yes No Yes
Individual’s Statement – Willingness to accept recommended level of care WI-UPC Recommended Level(s) of Service from Score 1 and/or Score 2 Alternative level(s) of service identified due to special circumstances outlined in Interviewer’s Comments Level(s) of care Level(s) of Care Name of Agency Individual is Being Referred Agency Telephone Number Agency Address SIGNATURE – Individual Date Signed SIGNATURE – Interviewer Date Signed
Date of birth* (m m / d d / y y y y): *Gender: Female Male Unknown Unspecified Not reported *Ethnicity(“X” ONLY one with which you MOST CLOSELY identify): Hispanic or Latino Not Hispanic or Latino Unknown Not Reported *Race (“X” those with which you identify): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Unknown Not Reported Additional Pediatric-specific Elements These elements are recommended for pediatric studies. *Date and time of birth: Date (m m / d d / y y y y): Time: AM PM 24-hour clock Maternal ethnicity (“X” ONLY one with which the mother MOST CLOSELY identifies): Hispanic or Latino Not Hispanic or Latino Unknown Not Reported Maternal race: (“X” those with which the mother identifies) Black or African-American White Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Unknown Not Reported Paternal ethnicity (“X” ONLY one with which the father MOST CLOSELY identifies):
Number of calendar days to commence services: _______________ Proposer must indicate the number of calendar days need to complete all work indicated in the Scope of Work from the date commencement to the completion of work date. Number of calendar days to complete project: ________________ 6.3 University’s Payment Terms University’s standard payment terms for services are “Net 30 days.” Indicate below the prompt payment discount that Proposer will provide to University: Prompt Payment Discount: _____%_____days/net 30 days. Respectfully submitted, Proposer: ____________________________ By: ___________________________ (Authorized Signature for Proposer) Name: _________________________ Title: __________________________ Date: _____________________
Professional Body Registration Date Membership Number Renewal Date Please indicate if you participate in CPD activities: I do participate I do not participate TO BE COMPLETED APPLICANTS IN CURRENT EMPLOYMENT Your current head of department and the chief executive of the owning institution in which you are employed must support this application. Head of Department Directorate / Divisional Manager or equivalent of the trust/owning institution Name: Name: Signature: Signature: Position held if not head of department: Position held if not Chief Executive: Date: Date:
Production Sites, Subcontractors (all the production unit entering in the process should be listed): company name & address contact name & information production stages Handler or subcontractor? Requested standards? Spoken languages In case of wet processing, does the unit treat the wastewater in an internal or external wastewater treatment plant before discharging to surface waters? Societé ABCD ZI Pont Peyrin, 36200 L'Isle Jourdain, France Name: Mr Dupont Email: dupont@abcd.fr Phone:+33-55555555 Fax:+33-5555553 dyeing handler GOTS & ERTS english,french yes Societé X ZI Pont Peyrin, 36200 L'Isle Jourdain, France Name: Mr Dupond Email: dupond@x.fr Phone:+33-5444444 Fax:+33-5444443 weaving NA GOTS & ERTS english,french NA Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax:
company name & address contact name & information production stages Handler or subcontractor? Requested standards? Spoken languages In case of wet processing, does the unit treat the wastewater in an internal or external wastewater treatment plant before discharging to surface waters? Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax: Name: Email: Phone: Fax:
Company Name: ……………………………………………………………………. Person in charge: …………………………………………………………………… Date: ………/…../…………… Signature and company seal: To be filled by Ecocert Greenlife SAS: . Review of application Yes/NO Comments Is the information given in the quote form sufficient to make an offer (e.g. filled completely, signed by the company asking for the certification)? (precise reasons if no) Is the List of products to be controlled filled in and are the products covered by the standard scope? (Eligible to certification, authorise materials….) (precise reasons if no) Is it possible for ECOCERT Greenlife to inspect and certify the project? (precise reasons if no) Conclusion: Are Ecocert able to make an offer to the company? Approved by: Date:
Hematologic/Lymphatic Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Integumentary (skin and/or breast) Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Musculoskeletal Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Neurological Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Psychiatric Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Respiratory Normal Abnormal Not examined Data to be filled in by site Clinically significant Not clinically significant Hand preference: (Hand participant/subject uses predominantly, not necessarily hand he/she writes with exclusively) Left hand Right hand Both hands Unknown
PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ANTIPSYCHOTIC DRUGS FOR CHILDREN 3 of 5 8 YEARS OF AGE AND YOUNGER F-00556 (01/2018) SECTION VI – MEDICATION USE (Continued) 25. Indicate below the child’s experience with psychoactive medication(s) other than the drug being requested. List the drugs and the highest daily doses achieved that the child is currently taking and has taken in the past in the spaces provided. Drug Class Current Past Alpha-2 Adrenergic Agonist Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Antidepressant Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Antipsychotic Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Stimulant Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Anticonvulsant / Mood Stabilizer / Lithium / All Other Drug Classes Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved SECTION VII – ADDITIONAL CLINICAL INFORMATION 26. Indicate if the child has the following symptoms. 1. Symptom(s) of persistent irritability / anger (daily or nearly daily) Yes No 2. Symptom(s) of temper outbursts (three or more per week). Yes No 3. Symptom(s) of anxiety. Yes No If yes to symptoms of anxiety, describe below. Continued
Lessons learned (e.g., describe what the team thought the outcome would be and what was the actual experience) Programmatic and/or financial impact of this change project (e.g., increased revenue, reduced costs, increased staff retention) Sustainability Plan (complete only if the team has adopted a change): Provide a summary of the sustainability plan. This summary should include: Changes to sustain Method and responsible person to make sure the change project is sustained Target goal System in place to measure and monitor that the process continues to meet the target goal Additional Notes:
DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-00926 (02/2017) STATE OF WISCONSIN Wisconsin Statutes § 51.61(1)(i) Administrative Code DHS 94.10 REQUEST FOR USE OF RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT AS PART OF A BEHAVIOR SUPPORT PLAN - CLTSS Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process. Personally Identifiable Information is collected on this form for the sole purpose of identifying the waiver participant and processing the request, and will not be used for any other purpose. Name - Consumer Birth Date Type of Request New Review Current Address - Consumer City State Zip Code Individual’s Applicable Target Group(s) (check all that apply): CLTSS-DD CLTSS-PD CLTSS-SED Name – Parent/Guardian Telephone Number - Parent/Guardian Current Residence - Consumer Personal/Family Residence (Same address as above) Licensed or Certified Facility, e.g., Foster Home, Adult Family Home, Shift Staff Treatment Foster Home (Provide name and address below.) Other (Describe and provide address below.) Residence Street Address (if different from above) City State Zip Code 1) Name – Waiver Provider/ Agency that will use the restrictive measure Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City State Zip Code Fax Number Email Address 2) Name – Waiver Provider/ Agency that will use the restrictive measure Waiver Service Type and Frequency Address- Waiver Provider/Agency Telephone Number City State Zip Code Fax Number Email Address County Waiver Agency Submitting This Request Date Submitted Contact Person/Support & Service Coord. Telephone Number Fax Number Email Address Address – Agency City State Zip Code Definitions Check “Yes” or “No,” if the following apply.
1.4 Who decides eligibility for the program? County Provider 1.5 Who decides amount or type of service from the program? County Provider 1.6 Payment method Unit-times-unit-price method and granting agency has independent means of knowing reasonability of price and number of units. All other payment methods 1.7 Competition Competitive basis Not competitive Other characteristics: 2 Provider Characteristics 2.1 Provider’s total funding from the Department Less than $200,000 Greater than $200,000 2.2 Provider’s length of time in business More than two years Less than two years 2.3 Provider’s experience and past performance Extensive experience and history of good performance Little to no experience or history of problems with performance 2.4 Provider’s financial health and practices No financial difficulties or problems with financial practices Financial difficulties or problems with financial practices 2.5 Provider’s compliance and internal controls No problems Some problems 2.6 Provider’s fiduciary responsibilities No fiduciary responsibility Provider has fiduciary responsibilities 2.7 Provider’s subcontracting Little to no subcontracting OR effective contract monitoring function Extensive subcontracting OR ineffective contract monitoring function Other characteristics: 3 County Characteristics 3.1 County’s experience with the provider agency Extensive experience Little to no experience 3.2 County’s experience with the program Extensive experience Little to no experience 3.3 County’s monitoring methods All significant risks covered by alternate monitoring Some significant risks not covered by alternate monitoring Other characteristics: Overall risk assessment: Low risk Moderate risk High risk
Fecha: Visión / Audición (examen, anteojos, audífonos, historial de infecciones del oído): Fecha: DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-00989CS (02/2017) STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01201 (02/2017) STATE OF WISCONSIN IRIS PARTICIPANT- HIRED WORKER SET- UP INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. A participant-hired worker may not begin working for a participant before the IRIS start date, indicated in the participant’s start date letter. Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the participant’s Fiscal Employer Agent. SECTION I – PARTICIPANT-HIRED WORKER DEMOGRAPHICS (all fields must be filled) Name – Participant-Hired Worker (Last, First, MI) Gender Male Female Date of Birth Mailing Address City Phone Number State Zip Email Address SECTION II – PARTICIPANT EMPLOYER DEMOGRAPHICS (all fields must be filled) Name – Participant Employer (Last, First, MI) Date of Birth Master Client Index (MCI) Mailing Address City Phone Number State Zip Email Address By signing below, I (we) agree the information on this form is accurate and I (we) have all supporting documentation in my possession. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. Both signers also acknowledge that no hours worked prior to a passed background check will be authorized. SIGNATURE – Participant Hired-Worker Date Signed SIGNATURE – Participant Employer Date Signed
RE: Notice of Action – IRIS Program Dear , IRIS Program policy requires that participants be notified when there is an adverse action defined as a denial, limitation, reduction, or termination of previously authorized services (meaning services/goods on a participant’s plan), requests for additional services, or when a participant is determined to be ineligible for the program. This notification is known as a Notice of Action (NOA). This notice is to inform you that your request for has been denied. Enclosed you will find a detailed copy of your Notice of Action, including why this decision was made, as well as your options to appeal this decision. You have forty-five (45) days from the date of this letter to request a State Fair Hearing. If you have any questions, please contact your IRIS Consultant. Sincerely, Amy Chartier, IRIS Section Chief Bureau of Adult Programs and Policies IRIS Management Section DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01204 (02/2018) STATE OF WISCONSIN NOTICE OF ACTION – IRIS PROGRAM Participant’s Name (Last, First) NOA Reference Number Decision Date Effective Date The purpose of this notice is to inform you about the IRIS Program’s decision to your The program has reached this decision based on the following factor(s): Informal support is available to provide sufficient support for your outcome. Specialized transportation definition does not cover reimbursement to yourself. The request does not meet an IRIS Medicaid Waiver Service definition.
25% of Australia’s total food and fibre exports Largest state exporter. Victoria’s share of food exports was 24% of Australia’s total food exports and 29% of Australia’s fibre exports Prepared foods 12% to be valued at $1.5 billion. The majority of the increase was in food preparations including soups, broths, and sauces and dietary foods Meat Victoria’s largest food and fibre export valued at $2.4 billion Sheep meat was the highest value meat product at just over $1 billion increasing by $89 million from the previous year Animal fibre Victoria’s second largest food and fibre export valued at $ 1.8 billion. Wool exports account for 95 per cent of this total. Fine and medium wool categories had the largest increases. Excellent seasonal conditions along with high wool prices contributed to the increase in export values Dairy Victoria’s third largest food and fibre export valued at $1.7 billion Table 1. Australian food^ and fibre^ exports by state of origin (A$ million, ‘000 tonnes) State of Origin 2012-13 2013-14 2014-15 2015-16 2016-17 $ change* % change* % total A$ Vol A$ Vol A$ Vol A$ Vol A$ Vol Victoria 10,927 12,190 12,153 10,113 12,252 9,029 12,112 8,544 12,833 11,224 720 6% 25%
the daily average. **This is required regardless of what is being requested. Home and Community Support Assessment. **This is required regardless of what is being requested. 11 Justification of hours on current plan above what is recommended by the Home and Community Support Assessment. Provide an explanation if the hours on the current plan are above what is recommended by the Home and Community Support Assessment. Situations that may be considered justified include extenuating circumstances such as seizure activity or behavioral needs that are not accounted for in the application of the Home and Community Support Assessment. 12 Describe the participant’s involvement in the community. Explain what involvement the participant has in the community – church, Special Olympics, clubs, activities with friends/family, etc. 13 Describe the natural supports available to the participant. Explain all supports the participant receives from unpaid supports that assist the participant in receiving needed care or being involved in the community. Include the relationship of the individuals providing (specific family, friend from church/work etc.), the type of support they provide, and the frequency of the support. 14 Describe how it was determined that the budget amendment request was the most cost-effective strategy. Provide a comparative analysis of all options available to meet the same end result and describe how the service/support/good presented in the budget amendment requested was determined to be the most cost-effective. This section should also detail any reason why the cheapest provider was not chosen. 15 If the participant is currently overspending their existing budget, explain why. Review the value entered in the column entitled “Variance in Actual Spend Plan Year to Date” in Section 2. If the value indicates underspending, enter “Not applicable – participant is spending within their budget.” If the value indicates overspending, provide an explanation as to why the overspending is occurring. Person Completing This Form The ICA staff that completes this form must also provide DHS with all relevant forms. When submitting this form, you are assuring that the information you provided has been verified and is accurate to the best of your knowledge. How to Submit This Form This form and any relevant accompanying forms should be attached electronically to the DHS Budget Amendment SharePoint site, in the appropriate participant’s file.
SECTION IV – ASSESSMENT Please provide detailed information about how you are living your day-to-day life. Be specific about the challenges that are keeping you from meeting your long term care goals and/or needs. 1. In my day-to-day life, I need assistance with the following that impact my safety, independence and mobility: Preparing Meals Entering/exiting my home Driving Bathing/dressing Other Please explain: Check the appropriate box to indicate which obstacles require assistance from others. 2. Barriers to my independence in my home, neighborhood and community include: My bathroom My kitchen My doorways My living areas My bedroom My vehicle Areas outside my home Other Please explain: Check the appropriate box to indicate which obstacles require assistance from others. 3. Describe any other relevant information or obstacles that affect your safety, independence or mobility. 4. Accessibility assessors may have different recommendations depending on your current health issues. Please share any relevant information about any medical conditions, current or upcoming, that may impact your independence.
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F-01234 (04/2018) FORWARDHEALTH EXPLANATION OF MEDICAL BENEFITS INSTRUCTIONS: Type or print clearly. If submitting a multiple page claim, include this form for each detail being billed. Refer to the Explanation of Medical Benefits Instructions, F-01234A, for more information. Providers should submit one completed form per payer. SECTION I – PAYER INFORMATION 1. Medicare Medicare Advantage Commercial Insurance SECTION II – MEMBER INFORMATION 2. Name – Member (Last Name, First Name, Middle Initial) 3. Member ID 4. Relationship to Policyholder SECTION III – PRIMARY POLICYHOLDER INFORMATION 5. Name – Primary Policyholder (Last Name, First Name, Middle Initial) 6. Primary Policy ID 7. Policy / Group Number SECTION IV – HEADER ADJUDICATION INFORMATION 8. Date Payer Processed 11. Paid / Deny 13. Allowed 15. Coins PR 2 17. Noncovered CO 96 19. Blood Deduct PR 66 21. ANSI Reason Codes ANSI Rsn Code Amount 9. From Date of Service 12. Billed Amount 14. Paid 16. Deductible PR 1 18. Copay PR 3 20. Psych Reduct PR 122 10. To Date of Service SECTION V – DETAIL ADJUDICATION INFORMATION Detail No. 22. Date Payer Processed 25. Paid / Deny 27. Proc. Code 29. Allowed 31. Coins PR 2 33. Noncovered CO 96 35. Blood Deduct PR 66 37. ANSI Reason Codes ANSI Rsn Code Amount 23. From Date of Service 26. Billed Amount 28. Revenue Code 30. Paid 32. Deductible PR 1 34. Copay PR 3 36. Psych Reduct PR 122 24. To Date of Service Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. Detail No. 22. 25. 27. 29. 31. 33. 35. 37. 23. 26. 28. 30. 32. 34. 36. 24. (Continued) EXPLANATION OF MEDICAL BENEFITS 2 of 2
DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01319 (02/2017) STATE OF WISCONSIN IRIS INVOLUNTARY DISENROLLMENT REQUEST INSTRUCTIONS: IRIS Consultant Agencies (ICAs) must complete this form to request approval from the Department of Health Services (DHS) to disenroll participants who have meet the criteria for involuntary disenrollment identified in IRIS Work Instruction Manual Section 7.1A.1. Wisconsin State Statute does not require the completion of this form; however, the IRIS program requires the completion of this form to process requests for the involuntary disenrollment of IRIS participants. Personally identifiable information on this form is collected to correctly identify the participant within the IT system, and will be used only for this purpose. SECTION I –DEMOGRAPHICS Participant’s Name (Last, First) Participant’s MCI Target Group DD PD FE Participant’s IRIS Consultant Agency Date of Last Face-to-Face Contac t Date of Last Attempted Face-to-Face Contact Date of Last Phone Contact Date of Last Attempted Phone Contact Reason for Disenrollment No Spend No Contact Health and Safety Residing in an Ineligible Living Setting Substantiated Fraud Mismanagement of Budget Authority Mismanagement of Employer Authority Refusal to Comply with IRIS Program Requirements SECTION II – Reason for Request Provide a detailed explanation of the reason for the request. SECTION III – Explanation of Attempted Mitigation Strategies Provide a detailed explanation of the mitigation strategies implemented to prevent involuntary disenrollment. SECTION IV – Conclusion Explain why the mitigation strategies were unsuccessful and involuntary disenrollment is the only option. SECTION IV – APPLICABLE TO NO CONTACT OR NO SPEND ONLY Date ICA Checked For Alternate Contact Information Date ICA Sent Initial Notification of Need for Contact Date ICA Sent Final Notification of Need for Contact Date of Last IRIS Expenditure My signature indicates that the information provided above is true and accurate to the best of my knowledge. SIGNATURE – IRIS Consultant Agency Representative Date Signed
Instructions: Insert number (#) of the Test Kit used beginning with #1. Make additional copies of this form as needed. Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable) Test Kit Information: # Manufacturer Manufacture Date Model Serial or Lot Number Expiration Date (if applicable)
Instructions: Complete for each testing location beginning with Location 1. Make additional copies of this form as needed. Results Testing Location Number Test Kit Used: Test Kit No.: Description of Tested Location and Component Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y)
Agency Name Reporting Month Date of Report Last Name, First Name, Address, Zip Code & Telephone Number DOB Re- screen Screen Date DOV Clinical Alert Value HTN Mgt Health Behavior Option / Follow-Up including Quit Line Referral 30-Day BP BG Yes Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
MODIFICATIONS TO THIS AGREEMENT CANNOT AND WILL NOT BE AGREED TO. THIS AGREEMENT IS NOT TRANSFERABLE OR ASSIGNABLE. Name – Provider Agency Head Title – Agency Head SIGNATURE – Provider Agency Head Date Signed Name – Administrator or Designee Division of Long Term Care SIGNATURE – Administrator or Designee Division of Long Term Care Date Signed Name – Agreement Administrator SIGNATURE – Agreement Administrator Date Signed
Hold meetings and conduct discussions and correspondence with one or more of the Proposers regarding their SOQs. Seek and obtain information or data, from any source, that may assist ADOT in evaluating the SOQs. Disqualify any Proposer under this RFQ, the RFP, or during the period between the RFQ and the RFP, for violating any rules or requirements of the procurement set forth in this RFQ, the RFP, or in any other communication from ADOT in connection with this procurement. Not issue a notice to proceed after financial close. Exercise any other right reserved or afforded to ADOT under this RFQ or applicable laws or regulations. Add or modify ADOT’s reserved rights in Addenda to this RFQ and the subsequent RFP. THE RFQ DOES NOT COMMIT ADOT TO ENTER INTO A CONTRACT OR PROCEED WITH THE PROCUREMENT AS DESCRIBED IN THIS RFQ. ADOT ASSUMES NO OBLIGATIONS, RESPONSIBILITIES, OR LIABILITIES, FISCAL OR OTHERWISE, TO REIMBURSE ALL OR PART OF THE COSTS INCURRED OR ALLEGED TO HAVE BEEN INCURRED BY PARTIES CONSIDERING A RESPONSE TO OR RESPONDING TO THIS RFQ, OR ANY SUBSEQUENT RFP. ALL SUCH COSTS SHALL BE BORNE SOLELY BY EACH PROPOSER. FURTHER, PURSUANT TO A.R.S. § 28-7705(H), THE CONTRACT PURSUANT TO THIS RFQ SHALL CONTAIN A PROVISION THAT IT IS SUBJECT TO A.R.S. TITLE 28, CHAPTER 20, ARTICLE 3, WHICH REFERS TO CERTAIN POWERS OF THE STATE TRANSPORTATION BOARD.
Name of Proposer: Key Personnel Position Name of Individual Years of Relevant Experience1 Education and Employing Firm Name Reference Name, Title, Telephone Numbers & Email Address3 Project Manager _____ years on October 1, 2017 1. 2. 3. Construction/ Installation Manager _____ years on October 1, 2017 1. 2. 3.
Name of Proposer: Key Personnel Position Name of Individual Years of Relevant Experience1 Education and Employing Firm Name Reference Name, Title, Telephone Numbers & Email Address3 Project Manager _____ years on October 1, 2017 1. 2. 3. Construction/ Installation Manager _____ years on October 1, 2017 1. 2. 3.
B. Describe the role of the entity in the space below, including equity ownership percentage. C. If the entity completing this Form L-1 is a joint venture or newly formed entity (formed within two (2) years before the SOQ Due Date), complete a separate Form L-1 and Form L2 for each member or partner of the entity and attach it to the SOQ. In addition, identify the name of such members or partners in the space below. Name Under penalty of perjury, I certify that the foregoing is true and correct, and that I am the firm’s Official Representative: By: _________________________________ Print Name: ____________________________ Title: ________________________________ Date: _________________________________ [Please make additional copies of this form as needed.]
Marketing and Outreach (Must be pre-approved by DHS) Lead: Back-up: Record Review Lead: Back-up: Record Requests Lead: Back-up: Participant and Provider Issues Lead: Back-up: Restrictive Measures and Behavior Support Plans Lead: Back-up: Training Lead: Back-up: HIPAA Breach Reporter and Incident Investigator Lead: Back-up: Customer Service Lead: Back-up: DHS Updates and Notification Emails - Distribution List Recipients: PROVIDER LEAD AND BACK-UP CONTACT INFORMATION NAME TITLE PHONE EMAIL
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-01571 (06/2015) STATE OF WISCONSIN Bureau of Environmental and Occupational Health AIR QUALITY MEASUREMENT DEVICE MAINTENANCE AND CALIBRATION LOG Date Time (AM / PM) Type of Equipment Serviced Activity Performed Comments Print Name of Person Conducting Maintenance EXAMPLE Carbon monoxide monitor; nitrogen dioxide monitor Calibration; bump test; leak test; other Passed pump test; failed pump test & recalibrated; passed leak test; failed leak test, etc.
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR BELSOMRA® 2 of 2 F-01673 (01/2016) SECTION III — CLINICIAL INFORMATION (Continued) 17. Has the member experienced an unsatisfactory therapeutic response or a clinically significant adverse drug reaction with at least two preferred drugs from the Sedative Hypnotics drug class? Yes No If yes, list the drug name and dates the drug was taken in the space provided for at least two preferred drugs the member has taken from the Sedative Hypnotics drug class. Drug Name Dates Taken Drug Name Dates Taken Drug Name Dates Taken Describe the unsatisfactory therapeutic response(s) or clinically significant adverse drug reaction(s). SECTION IV — AUTHORIZED SIGNATURE 18. SIGNATURE — Prescribing Provider 19. Date Signed SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA 20. National Drug Code (11 Digits) 21. Days’ Supply Requested (Up to 365 Days) 22. NPI 23. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14 days in the past.) 24. Place of Service 25. Assigned PA Number 26. Grant Date 27. Expiration Date 28. Number of Days Approved SECTION VI — ADDITIONAL INFORMATION 29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.
C. Food Storage and Inventory Yes Needs Attention No 1. Are the kitchen and food preparation areas clean? Comments: 3. Are dry storage floors, walls, ceiling and shelving clean? Comments: 4. Are there cleaning logs that record what was cleaned and when? Comments: Yes No 5. Is there at least 4” between food and walls (both in all dry storage and in walk-in units)? Comments: 6. Is food stored at least 6” off of the floor (in both dry storage and walk-in units)? Comments: 7. Is food in dry goods areas stored at least 24” below the ceiling? Comments: 8. Do temperature logs regularly record interior temperatures of freezers and refrigerators? Comments: 9. Are recorded freezer temperatures at 0 degrees Fahrenheit or colder? Comments: 10. Are recorded refrigerator temperatures between 35 and 41 degrees? Comments: 11. Are recorded dry storage temperatures consistently within degrees Fahrenheit? Comments: 12. How are pests controlled? Contracted Self-inspection/remediation No apparent pest control (If self-inspection, describe the actions the Shelter takes and when):
REPORT Vaccine TOTAL doses ordered Total doses administered – Event 1 Total doses administered – Event 2 Total doses administered – Event 3 Total doses administered POD location(s): POD location(s): POD location(s): Date range: Date range: Date range: Influenza
2: (IP) 2, Capability Observation Title Recommendation (what needs to be fixed) Corrective Action Description (how are you going to fix it) Capability Element Primary Responsible Agency Agency POC (Title is preferable) Start Date Completion Date Emergency Public Information and Warning Insert Observation Insert Recommendation Insert Corrective Action You can choose from the following capability elements: Planning, Organization, Personnel, Equipment, Training, or Process LPHA Health Officer 10/1/18 3/1/19 2 3 1 2 3 1 2 3 1 2 3
Appendix D - Personnel Worksheet 2017 Please include all ADRC staff. Please report subcontracted staff in the designated section. Under the “All Functions” column include: I&A, Options Counseling, Enrollment Counseling, LTCFS, DBS, outreach, and any other ADRC service the employee performs. A function is considered an ADRC function if it is included in the ADRC Scope of Services of the contract. Include activities such as APS if applicable. Include only one staff member per line. See the example below. Position Title (please indicate if LTE) Employee Name (full first and last name) If AIRS Meets and Waiver of Education and experience approved by ORCD All Functions (ADRC and other) performed by this individual (see example below; include % of time for ADRC and Total FTE for this Person Annual Salary (not fringe) % FTE Funded by ADRC funding (all funds see note, page 5) % FTE Funded by Other Source (list source) Method for allocation of Split Funded Positions Directors/Supervisors Section 100% Time Reporting By FTE By Work Effort ADRC Director John Doe Plans, directs, implements and monitors operations of the ADRC 50% and the OAA Programs 40%, and Adult Protective Services 10%. 1.00 78,000 50% 40% OAA 10% County Levy Other Staff Section 100% Time Reporting By FTE By Work Effort I & A Jane Smith I&A, options 1.00 40,000 100%
NOTES: January S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 February S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 21 23 24 25 26 27 28 March S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 21 23 24 25 26 27 28 29 30 31 NOTES: April S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 May S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 June S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 NOTES: July S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 August S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 September S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 NOTES: October S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 November S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 21 23 24 25 26 27 28 29 30 December S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Operational Issues we institute this as an “interim” policy and revisit it at the end of FY’18 after we’ve assessed the impact of the transition to Fee For Service. The Upcoming Presentation of the FY17 Audited Financial Statements by Holman Frenia Allison, PC to this committee was discussed. June Noto presented a brief synopsis of the NJAMHAA building move, which was completed at the end of July; as well as a brief update on the video conferencing purchases, which should be completed in FY’18. It was decided that the Audited Financial Statement Presentation would take place on Sept 28th N/A Sept 28th, 10am At NJAMHAA N/A Holman Frenia Allison, Debra Wentz, Julia Schneider N/A The Committee Co-chair motioned to adjourn the meeting. M/S/P N/A N/A Next regular meeting date – December 11, 2017 at 10 am at NJAMHAA Headquarters.
Registered Nurse Degree Apprenticeship Application Form As the apprentice remains employed for the duration of the apprenticeship, the employing organisation is responsible for supporting/guiding the applicant in the application process. When the application form is completed by the apprentice and employer, the employer is then responsible for sending the completed application form to: . Applicants approved by their employers will then be invited for interview. 1.Programme Programme Title and Campus: Programme Code: For office use only Start date (Month/Year): 2.Personal details : Please use your full legal names* Surname (Family name): First names: Title Previous name/Maiden name: (as at 16th birthday) Date of Birth: Legal gender status: Other: Country of Birth: Nationality: Ethic Origin: Country of Permanent Residence: Have you lived in this Country or the EU/EEA for the last 3 years (not for the purpose of study): Please specify your religious belief: 3.Fee Status Payment of fees: Apprenticeship Other (Please specify) If SLC, name Local Authority: Have you previously received an educational award from UK public funds? YES / NO If so, please provide details: Funding body Course Dates