zilongwang/ReadingBank huggingface dataset:
TIME When and for how long the content will be taught STANDARD Listing of the exact Standard as adopted CURRICULUM UNIT CONNECTIONS Notations regarding the alignment to developed units ASSESSMENTS How and when students will be assessed List month List the broad topic as a header for each section. List the standard # and standard narrative. List the standards together that will be taught together. List the title of available Massachusetts DOE Curriculum Units. This will also serve as a placeholder for Curriculum Unit notations to be developed by teachers locally. List the appropriate State assessment and timing of such. List pre-assessment List available Curriculum Embedded Performance Assessments (CEPAs). This will also serve as a placeholder for teachers to insert local assessments. CURRICULUM MAP TEMPLATE SUBJECT – GRADE LEVEL Resources MA Curriculum Framework for Mathematics PARCC Model Content Framework Current curriculum maps and materials ESE Crosswalks
Family Tree Clinic FamilyWise Services Hennepin County Library – Franklin Learning Center (FLC) Fraser Fred Wells Tennis and Education Center Free Arts Minnesota Free Arts Minnesota – YWCA St. Paul Free Arts Minnesota – Boys and Girls Club Eastside Free Arts Minnesota – Boys and Club Mt. Airy Free Arts Minnesota – Cornerstone Free Arts Minnesota – Dayton’s Bluff Free Arts Minnesota – Emma’s Free Arts Minnesota – Jeremiah Program Minneapolis Free Arts Minnesota – Jeremiah Program St. Paul Free Arts Minnesota – Kaleidoscope Free Arts Minnesota – Northside Child Development Center Free Arts Minnesota – People Inc. Free Arts Minnesota – People Serving People Free Arts Minnesota – Perspectives Free Arts Minnesota – Sojourner Free Arts Minnesota – St. Anne’s Place Free Arts Minnesota – St. Josephs Home for Children Free Arts Minnesota – Tubman Friends of the Boundary Waters Friends of the Mississippi River Gardening Matters Gigi’s Playhouse Ginew/Golden Eagle Program Girl Scouts of Minnesota and Wisconsin River Valley Girls on the Run Twin Cities Goodwill/Easter Seals Minnesota Gordon Parks High School – St. Paul Public Schools River Greening Guthrie Theater Habitat for Humanity ReStore Hennepin County Adult Field Services Community Corrections and Rehabilitation Hennepin County Juvenile Probation Hennepin County Library – Augsburg Park Hennepin County Library – Franklin (This site hosts Urban 4-H and Franklin Learning Center) Hennepin County Library – Roosevelt Hennepin County Library – Sumner Hennepin County Library – Brookdale Hennepin County Library – Brooklyn Park Hennepin County Library – Minneapolis Central
Tubman – Chrysalis Center Tubman – Harriet Tubman Center East Tubman – Harriet Tubman Center West (This site Free Arts) Twin Cities Habitat for Humanity Twin Cities Industrial Workers of the World (IWW) United Hospital University of Minnesota Medical Center (Two Locations) University of Minnesota ReUse Program Warehouse 4-H – Franklin Library Urban 4-H – Humboldt High School Urban 4-H – Neighborhood House Urban 4-H – Farnsworth Middle Urban 4-H – Franklin Housing Cooperative Urban 4-H – Highland Park Middle School 4-H – Murray Middle School Urban 4-H – Extension Center for Youth Development Roots Urban Ventures Venture Academy (This site hosts East Side Neighborhood Services Inc. EMERGE Youth Program) VIP – Robbinsdale Area Schools Vision Loss Resources Waite House – Pillsbury United Communities Walk-In Counseling Center Wellstone International High School - Minneapolis Public School We Win Institute We Win Institute – North Side West African Medical Missions West Bank Business Association Wilder Community Center for Aging Wildlife Rehabilitation Center of Minnesota Windom Enrichment Resource Center (WERC) Women of Nations Women’s Initiative for Self Empowerment (WISE), Inc. (Five Locations) WomenVenture Yinghua Academy YMCA of the Greater Twin Cities – UY Farm YouthCare YouthCare – Little Earth of United Tribes YouthCare – McDonough Youthlink YWCA of St. Paul (This site hosts Free Arts)
East Side Neighborhood Services Inc. – Venture Academy EMERGE Program Ebenezer Minneapolis Campus El Colegio Charter School English Learning Center Eureka Recycling FAIR School Fairview Home Care and Hospice Family Place Family Service Rochester Family Tree Clinic FamilyWise Services GRACE, Inc. Hennepin County Library – Franklin Learning Center (FLC) Feed My Starving Children - Chanhassen Feed My Starving Children - Coon Rapids Feed My Starving Children - Eagan Franklin Middle School Math Tutoring Franklin Skynet Junior Scholars Fraser Fred Wells Tennis and Education Center Free Arts Minnesota Free Arts Minnesota – YWCA St. Paul Free Arts Minnesota – Boys and Girls Club Eastside Free Arts Minnesota – Boys and Girls Club Mt. Airy Free Arts Minnesota – Cornerstone Free Arts Minnesota – Dayton’s Bluff Free Arts Minnesota – Emma’s Place Free Arts Minnesota – Jeremiah Program Minneapolis Free Arts Minnesota – Jeremiah Program St. Paul Free Arts Minnesota – Kaleidoscope Free Arts Minnesota – Northside Child Development Center Free Arts Minnesota – People Inc. Free Arts Minnesota – People Serving People Free Arts Minnesota – Perspectives Free Arts Minnesota – Sojourner Free Arts Minnesota – St. Anne’s Place Free Arts Minnesota – St. Josephs Home for Children Free Arts Minnesota – Tubman Friends of the Boundary Waters Friends of the Mississippi River Gardening Matters Ginew/Golden Eagle Program Girl Scouts of Minnesota and Wisconsin River Valley Girls on the Run Twin Cities
MN Department of Natural Resources – MNDNR Volunteer Programs Minnesota Internship Center Charter High School – Downtown Minnesota Internship Center Charter High School – Sabathani Minnesota Internship Center Charter High School – St. Paul Minnesota Internship Center Charter High School – Unity Minnesota Literacy Council Minnesota Reading – American Indian Magnet Minnesota Reading Corps – Jenny Lind Elementary Minnesota Reading – Waite Park Elementary Minnesota Transgender Health Coalition Minnesota Veterans Home - Minneapolis MN Break the Bonds (Minnesota Public Interest Research Group) Mu Performing Arts Murray Middle School – St. Paul Public Schools (This site hosts Urban 4-H) NAMI Minnesota NARAL Pro-Choice Minnesota Navigate Neighborhood HealthSource - Central Community Clinic Neighborhood HealthSource - Fremont Community Clinic Neighborhood HealthSource - Minneapolis Urban League Neighborhood Involvement Program (NIP) - Senior Programs Neighborhoods Organizing for Change Neighbors Inc. Normandale Center for Healing and Wholeness North High School North Memorial SafeJourney Northern Voices NorthPoint Health and Wellness Center NPH USA Occupy Homes MN Open Arms of Minnesota Open Door Learning Center - Lake Street Open Door Learning Center – North Side Open Door Learning Center – Northeast Open World Learning Community – St. Paul Public School OutFront Minnesota Patrick’s Cabaret PEASE Academy People Serving People, Inc. (This site hosts Free Arts) Perspectives Family Center (This site Free Arts) Phillips Eye Institute – Early Youth Eyecare Phillips Neighborhood Clinic Pillsbury House
Standards listed by reference, including revisions by issuing authority, form a part of this specification section to extent indicated. Standards listed are identified by issuing authority, authority abbreviation, designation number, or other designation established by issuing authority. Standards subsequently referenced herein are referred to by issuing authority and standard designation. International Organization for Standardization (ISO) ISO 1856 – Compression Set ISO 1798 – Tensile Strength ISO 1798 – Elongation at Break ISO 34-1 – Tear Resistance ISO 3386-2 – Compression Hardness ISO 8307 – Rebound Elasticity ISO – Ozone Resistance European Standardization Organizations CEN, CENELEC, ETSI (EN) EN 826 – Static Modulus of Elasticity EN 14904 – Force Reduction German Institute for Standardization (DIN) DIN 53513 – Dynamic Modulus of Elasticity DIN 53513 – Mechanical Loss Factor Leadership in Energy and Environmental Design – LEED® ISO 14021 - Environmental Labels and Declarations System Description ***********This product may contribute to LEED Credits*********** Performance Requirements: Provide recycled re-bonded underlayment, which has been manufactured and installed to maintain performance criteria stated by manufacturer without defects, damage, or failure. Submittals General: Submit listed submittals in accordance with Conditions of the Contract and Division 1 Submittal Procedures Section. Product Data: Submit product data, including manufacturer’s guide specifications product sheet, for specified products. Shop Drawings: Manufacturer’s specifications, catalog cuts, and other items needed to demonstrate compliance with the specified requirements. Also the manufacturer’s recommended installation procedures, which, when approved by the architect, will become the basis for accepting or rejecting actual installation procedures used on the work. Samples: Submit selection and verification samples for finishes, colors, and textures. Quality Assurance Submittals: Submit the following: Certificates: If required, certification of performance characteristics specified in this document shall be provided by the manufacturer. Manufacturer’s Instructions: Manufacturer’s installation instructions. Closeout Submittals: Submit the following:
Standards listed by reference, including revisions by issuing authority, form a part of this specification section to extent indicated. Standards listed are identified by issuing authority, authority abbreviation, designation number, title, or other designation established by issuing authority. Standards subsequently referenced herein are referred to by issuing authority and standard designation. International Organization for Standardization (ISO) ISO 1856 – Compression Set ISO 1798 – Tensile Strength ISO 1798 – Elongation at Break ISO 34-1 – Tear Resistance ISO 3386-2 – Compression Hardness ISO 8307 – Rebound Elasticity ISO 17025 – Ozone Resistance European Standardization Organizations CEN, CENELEC, ETSI (EN) EN 826 – Static Modulus of Elasticity EN 14904 – Force Reduction German Institute for Standardization (DIN) DIN – Dynamic Modulus of Elasticity DIN 53513 – Mechanical Loss Factor Leadership in Energy and Environmental Design – LEED® ISO - Environmental Labels and Declarations System Description ***********This product may contribute to USGBC LEED Credits*********** Performance Requirements: Provide recycled re-bonded underlayment, which has been manufactured and installed to maintain performance criteria stated by manufacturer without defects, damage, or failure. Submittals General: Submit listed submittals in accordance with Conditions of the Contract and Division 1 Submittal Procedures Section. Product Data: Submit product data, including manufacturer’s guide specifications product sheet, for specified products. Shop Drawings: Manufacturer’s specifications, catalog cuts, and other items needed to demonstrate compliance with the specified requirements. Also the manufacturer’s recommended installation procedures, which, when approved by the architect, will become the basis for accepting or rejecting actual installation procedures used on the work. Samples: Submit selection and verification samples for finishes, colors, and textures. Quality Assurance Submittals: Submit the following: Certificates: If required, certification of performance characteristics specified in this document shall be provided by the manufacturer. Manufacturer’s Instructions: Manufacturer’s installation instructions. Closeout Submittals: Submit the following:
Wilderness Tourism Association of BC. 2008. The of Wild Salmon to BC’s Nature Based Tourism Industry and the Impacts of Open Net Cage Salmon Farming, April 30, 2008, Withler, F. C. 1982. Transplanting Pacific salmon. Canadian Technical Report of Fisheries and Aquatic Science 1079:27. Wolfe, D. A., M. Hameedi, J. J. A. Galt, G. Watabayashi, J. Short, C. O'Clair, S. Rice, J. Michel, J. R. Payne, J. Braddock, S. Hanna, and D. Sale. 1994. The fate of the oil spilled from the Exxon Valdez. Environmental Science and Technology 28:561A-568A. Wood, C.. 2001. Managing biodiversity in Pacific salmon: The Evolution of the Skeena River Sockeye Salmon Fishery in British Columbia. Prepared by World Fisheries Trust for the Biodiversity Planning Support Program established by the United Nations Development Program and the United Nations Environment Program. Wright, N. 2002. Eelgrass conservation for the B.C coast. B.C Coastal Eelgrass Stewardship Project.
RAE Risk Analysis Event RAV Risk Analysis Valuation RI Runway Incursion SMS Safety Management System SOP Standard Operating Procedure SRM Safety Risk Management SRMD FAA Safety Risk Management Document (also known as a “safety case”, or “safety assessment”) ICAO Universal Safety Oversight Audit Program
Doc 9815 Manual on Laser Emitters and Flight Safety Doc 9817 Manual on Low-level Wind Shear Doc 9830 Advance Surface Movement Guidance and Control System (A-SMGCS) Manual Doc 9854 Global Air Traffic Management Operational Concept Doc 9859 Safety Management Manual (SMM) Doc 9863 Airborne Collision Avoidance System (ACAS) Manual Cir 120 Methodology for the Derivation of Separation Minima Applied to the Spacing between Parallel Tracks in ATS Route Structures Global Operational Data Link Document (GOLD) Cir 185 — Satellite-aided Search and Rescue — The COSPAS-SARSAT System Cir 211 — Aerodrome Flight Information Service (AFIS) Cir 241 — Human Factors Digest No. 8 — Human Factors in Air Traffic Control Cir 247 — Human Factors Digest No. 10 — Human Factors, Management and Organization Cir 249 — Human Factors Digest No. 11 — Human Factors in CNS/ATM Systems Cir 257 — Economics of Satellite-based Air Navigation Services Cir 267 — Guidelines for the Introduction and Operational Use of the GNSS Cir 278 — National Plan for CNS/ATM Systems Cir 305 — Operation of New Larger Aeroplanes at Existing Aerodromes Partial List of ICAO Reference Documents – AIG – Search and Rescue Doc 7300 Convention on International Civil Aviation Annex 13 Aircraft Accident and Incident Investigation Doc 9734 Safety Oversight Manual Part A The Establishment and Management of a State’s Safety Oversight System Doc 9756 Manual of Aircraft Accident and Incident Investigation Part I Organization and Planning Part II Procedures and Checklists Part III Investigation Part IV Reporting Doc 9859 Safety Management Manual Doc 9946 Manual on Regional Accident and Incident Investigation Organization Doc 9962 Manual on Accident and Incident Investigation Policies and Procedures Cir 285-AN/166 — Guidance on Assistance to Aircraft Accident Victims and their Families Cir 298-AN/172 — Training Guidelines for Aircraft Accident Investigators Cir 315-AT/179 — Hazards at Aircraft Accident Sites
Estimated Risk Has the risk of the proposed change been estimated? Have the methodology and tools used to determine the risk been described in the document? Severity is determined by the credible potential outcome. Have the most severe effects been considered? Is the scope of the safety case appropriate to any high risk(s) identified? Are initial risks and residual risks (post-proposed mitigations) identified in the Hazard Analysis Worksheet(s)? Is the residual risk at or below an acceptable level? Hazard Mitigation Have the hazard mitigation strategies and control efforts been identified and documented? Has the methodology for tracking hazards and verifying effectiveness of mitigation controls throughout the lifecycle of the system or change been identified and documented?
2.2 THE STATE SAFETY PROGRAMME The objective of the SSP is to achieve an acceptable level of safety of aviation services and products delivered by aviation service providers - aircraft operators, air navigation service providers, airport operators, training and maintenance organizations. A successful SSP builds on safety management principles to ensure aviation safety across the spectrum of the State’s aviation system. 2.2.1 Annex 19 to the Chicago Convention contains the requirements for a State to establish an SSP. The SSP framework is described in detail in the ICAO Safety Management Manual. 2.2.2 The primary components of the SSP framework, which align with the components of an SMS, describe the State’s responsibilities for safety management. These responsibilities include, among others: safety regulation; safety oversight; accident investigation; safety data collection, analysis, and exchange; enforcement, and communication of safety information.
Explain why the marginal revenue of the fourth unit of output is $3.50, even though its price is $5.00. Use Chapter 6's total-revenue test for price elasticity to designate the elastic and inelastic segments of your graphed demand curve. What generalization can you make as to the relationship between marginal revenue and elasticity of demand? Suppose the marginal cost of successive units of output was zero. What output would the profit-seeking firm produce? Finally, use your analysis to explain why a monopolist would never produce in the inelastic region of demand: Answers: Table of total revenue and marginal revenue is below: Price (P) Quantity Demanded (Q) Total Revenue Marginal Revenue $7.00 $6.50 $6.00 $5.50 $5.00 $4.50 $4.00 $3.50 $3.00 $2.50 0 1 2 3 4 5 6 7 8 9 $0 $6.50 $12 $16.50 $20 $22.50 $24 $24.50 $24 $22.50 $1 $6.50 $5.50 $4.50 $3.50 $2.50 $1.50 $0.50 $ -1.50 See the Because TR is increasing at a diminishing rate, MR is declining. When TR turns downward, MR becomes negative. Marginal revenue is below D because to sell an extra unit, the monopolist must lower the price on the marginal unit as well as on each of the preceding units sold.
Does not meet requirements Does not meet requirements Meets requirements Meets requirements Meets requirements Significantly below criteria required for successful job performance Demonstrates behaviours that have negative outcomes or consequences Insufficient for effective performance Does not meet criteria for effective performance Does not demonstrate a sufficient range of skills for handling the situation Acceptable for effective performance Meets criteria for effective performance Demonstrates a sufficient range of skills for handling the situation More than acceptable for effective performance Consistently demonstrates better than average of performance Requires limited direction in complex situations Exceeds expectations in most to all areas with superior results Requires limited direction in complex situations Part 1: General Verification Questions Employment Relationship Notes: In what capacity was the applicant employed by your organization? What were the dates of employment? Notes: In what capacity was the applicant employed by your organization? Please describe the applicant’s key functions: Notes: What was the applicant’s reason for leaving? Notes: Part 2: Job Specific Questions - Knowledge, Skills, Abilities and Competencies Insert Factor Assessed: Insert Question: Score or Pass/Fail: Insert Factor Assessed: Insert Question: Notes: or Pass/Fail: Insert Factor Assessed: Insert Question: Score or Pass/Fail: Part 3: Overall Performance Questions
The UNICEF Guidance for Civil Society Partnering with UNICEF is shared with partners to assist them in development the programme document. During the development of the programme document, workplan and budget, UNICEF Programme Officers evaluate whether: The total amount of resources to be provided by UNICEF represents value-for-money given the likely results to be achieved; and All activities contribute, in a cost-effective manner, to the achievement of the planned results. All resource requirements are assessed for their relevance to the implementation of the activities and the achievement of the planned results. UNICEF Offices provide resources for the reasonable cost of activities considering the context. CSO Partner Responsibility In to accurately estimate the resources needed for each activity, the partner prepares detailed cost estimates of inputs for each activity, ensuring all costs are associated with the activities of the workplan. The compiled activity level costs are then incorporated into the draft programme document for discussion with the UNICEF Programme Officer, who may request additional information to better understand the estimates sited. Overall, UNICEF Office’s ensure that workplan budget activities and their associated input requirements are implemented in a manner that is aligned with economy, efficiency and effectiveness. The programme document workplan and budget includes any important ‘non-financial contributions’ from both UNICEF and the partner. ‘Non-financial contributions’ are inputs other than cash or programme supplies which are directly used towards the achievement of the partnership’s planned results. Community mobilization or local knowledge inputs by community based organizations (CBOs) are important examples of non-financial contributions and should be incorporated within the programme document workplan and budget. An estimated value of non-financial contributions is not required. Programme Document Workplan Budget The workplan budget represents the estimated cost of implementing activities and achieving results defined in the programme document. The workplan and budget provide the basis for programme and financial performance management and monitoring achievement of jointly planned results. A common understanding between the UNICEF Programme Officer and the partner is reached on the resource requirements to implement activities and achieve results. Similarly, these parties also agree upon (and document) the nature of each partner’s contribution (i.e., whether it will be in cash, or supplies, or in-kind). The workplan budget is divided into two categories: Programme Costs and Headquarters Support Costs. Programme All costs to carry out activities are included in the programme document workplan budget. ‘Programme Costs’ are costs that can be attributed to a specific activity
TEMA+ Secretary : ELTE BTK Atelier 1088 Budapest Múzeum krt. 6-8. Phone/fax: +36 1 485-5200/5234 E-mail: secretary@mastertema.eu http://www.mastertema.eu REFERENCE This reference is part of the application form for the TEMA+ European Territories: Heritage and Development Erasmus Mundus Joint Master Programme. The TEMA+ Pedagogic Council kindly ask you to fill in this form and transmit it in a signed and sealed envelope to the applicant, who will submit it attached to the application. Thank you for assisting us in our admission process. Applicant Family name: First name: Citizenship: Referee Family name: First name: Position/Affiliation: Institution: Telephone: Fax: E-mail: How long have you known the applicant? In what capacity have you known the applicant?
Substance Use TBI and Risk Reduction Teaching Tools for trainees on understanding neuroanatomy and neuropsychiatry PTSD Guides and references for providers PTSD Guides and references for Veterans and families Common Symptom Education Guides for patients Epidemiological Data on Common Diagnoses and numbers of Veterans treated PTSD Consultation Services with the National Center for PTSD General Facts on Chronic Pain in OIF/OEF/OND Veterans Course # 13260: chronic pain CPG for Patients at Risk for Suicide CPG for PTSD CPG for mild TBI CPG for OTCP Consensus Conference Recommendations for Treating patients with mild TBI, PTSD, and Pain Mobile Phone APP for Concussion symptom
No, because this is a rewards program, no tax forms will be sent. Does ReferLive share member information with anyone? No, this information is kept very secure and is not sold to any third parties. Will there be any reminder emails sent? Reminder emails will be sent to the potential member on day 3 and day 7 if the person does not register into the program. Do referrals expire? Yes, a referral is good for 90 days. What happens when two people refer the same person? The first person that referred gets the referral credit.
Note to referrer: If the applicant is a 16/17 year old and not a looked child this CRF must be signed off by a YSS consultant Social Worker and the Housing Development Manager before sending to a provider. Note to provider receiving this referral: This referral should not be accepted under any circumstances if approval has not been granted in the box below within the last one month. If approval has not been granted please return the referral to the originator. Name: Approval granted to access supported accommodation? Date: Reasons for approval / refusal and recommendations for accommodation type i.e. Supported Lodgings, Hostel, Foyer, Shared, Female only. Please also confirm that the young person is Homeless (Southwark Judgement) and is unable to return home due to safeguarding concerns. YSS Placement Review Date: YSS Housing Development Manager / HPS Manager YES NO Name: YSS Area Consultant Social Worker approval YES NO 1. Referrer Name of referrer Phone no Referral Organisation Email address Postal address Fax Number How long have you known the applicant? Reason for referral and supporting statement e.g. overcrowding, sleeping rough, financial difficulties, eviction, prison discharge, experiencing harassment / abuse, leaving temporary accommodation, family difficulties. Please state how soon the applicant requires accommodation: Family Relationship: please give the reasons why the family relationship has broken down and current contact with family; have extended family members been contacted; has mediation been attempted etc? Emergency Bed. Has the applicant been referred to an emergency bed? If Yes one and what is the status of the referral? I confirm that the information provided in this form is, to the best of my knowledge, full and accurate at the time of completion. Signed by referrer (please type name if completing on computer) Date
Appendix 2 REFERRAL MATRIX TO ASSESS LOCAL CONNECTION: to be completed by all LAC/ Care Leavers aged 16+ and 16/17 year old young people open to YSS who are not LAC to ascertain strongest Local Connection for the purpose of Housing Registration. This Matrix should be attached the Housing Registration Forms for the relevant Local Housing Authority. 1. Current Residence - have they lived there 6 months out of the last 12 2. Current residence - have they lived there 3 years out of the last 5 years? 3. Are they employed in the area ? 4. Do they have close family living in the areas (1 step removed) who have lived there for over 5 years ? Are they at risk in the area Client preference? Elmbridge Epsom and Ewell Guildford Mole Valley Reigate and Banstead Runnymede Spelthorne Surrey Heath Tandridge Waverley Woking
Bristol Communication Aid Service / Dame Hannah Rogers Trust Referral Form Name: Address (inc postcode): Telephone: Email: Clinical Commissioning: Client Details Name: Date of Birth: Address (inc postcode): 5 Telephone: Email: NHS number: Next of kin name: Address(es): (if different from above) Telephone: School/Pre-school: Address: Telephone: Is the person able to travel to their local AAC centre (BCAS/DHRT)? (NB, home/school visits will only be considered in exceptional circumstances) Yes No Is the person’s first language English? Yes No Do the family require an interpreter? Yes No If yes what language? Days available for appointments: (referrer & client) For Adult referrals only: Does the person require hospital transport? Will an escort be accompanying the person? Yes No Make and model of wheelchair used for travel if appropriate: Other professionals involved (including GP & Paediatrician): GP DETAILS MUST BE GIVEN OR REFERRAL WILL BE REJECTED Name Professional Address Tel Number
PAEDIATRIC SPEECH & LANGUAGE THERAPY PRE SCHOOL REFERRAL FORM Parent / Carer consent gained for: YES NO Referral to the Speech and Language Therapy Service (and to assessment and treatment if appropriate) Sharing of records with other health & education professionals: Receive SMS text appointments: Parent/ Carer signature: ……………………………….…………………… Date: ……………………...……… Child’s Details: Forename: Surname: Date of Birth: Gender: Male / Female Address: Postcode: NHS Number (if known): Telephone No: Mobile: GP Name: GP Practice: Main Language: Child’s other language/s: Ethnic Origin: Religion: Medical Diagnosis: Parent/ Family Details: Parent Name/s: Parent’s Main Language: Dialect: Does the parent require an interpreter: YES / NO Does the child require an interpreter: YES / NO Preferred gender of interpreter: Male / Female / Either Family history of Speech & Language difficulties (please state relationship to child & diagnosis): Name of Therapist who saw sibling: Safeguarding: YES NO
PAEDIATRIC SPEECH & LANGUAGE THERAPY PRE SCHOOL REFERRAL FORM Parent / consent gained for: YES NO Referral to the Speech and Language Therapy Service (and to assessment and treatment if appropriate) Sharing of records with other health & education professionals: Receive SMS text appointments: Parent/ Carer signature: ……………………………….…………………… Date: ……………………...……… Child’s Details: Forename: Surname: Date of Gender: Male / Female Address: Postcode: NHS Number (if known): Telephone No: Mobile: GP Name: GP Practice: Child’s Main Language: Child’s other language/s: Ethnic Origin: Religion: Medical Diagnosis: Parent/ Family Details: Parent Name/s: Parent’s Main Language: Dialect: Does the parent require an interpreter: YES / NO Does the child require an interpreter: YES / NO Preferred gender of interpreter: Male / Female / Either Family history of Speech & Language difficulties (please state relationship to child & diagnosis): Name of Therapist who saw sibling: Safeguarding: YES NO
PAEDIATRIC SPEECH & LANGUAGE THERAPY SCHOOL AGE REFERRAL FORM Parent / Carer consent gained for: YES NO Referral to the Speech and Language Therapy Service (and to assessment and treatment if appropriate) Sharing of records with other health & education professionals: Receive SMS text appointments: Parent/ Carer signature: ……………………………….…………………… Date: ……………………...……… Details: Forename: Surname: Date of Birth: Gender: Address: Postcode: NHS Number (if known): Telephone No: Mobile: Patient Access Information Requirement: GP Name: GP Practice: Child’s Main Language: Child’s other language/s: Ethnic Origin: Religion: Medical Diagnosis: Parent/ Family Details: Parent Name/s: Parent’s Main Language: Dialect: Does the parent require an interpreter: YES NO Does the child require an interpreter: YES NO Preferred gender of interpreter: Either Family history of Speech & Language difficulties (please state relationship to child & diagnosis): Name of Therapist who saw sibling: Safeguarding: YES NO
Cancer Rehabilitation Program OUTPATIENT REFERRAL FORM Patient’s Name: ______________________________________ Patient’s MR#: ______________________________________ Patient’s _______________________________________ Patient Dx: _______________________________________ Referring Physician: __________________________________________ Physician __________________________________________ Currently an inpatient? □ Yes □ No If inpatient, expected discharge date: __________________________________________ Please check appropriate box(es): Referral to Cancer Rehabilitation Program: Other Services Available: □ Evaluate and Treat Physical Therapy Occupational Therapy** Physiatry** □ Rehabilitation Psychology** □ Speech-Language Pathology** **Only available at downtown Baltimore campus** Reason for Referral: Physician Signature:__________________________ Date: ______________________ ***To Schedule an Appointment Call: 410-614-3234***
Medway Active Recovery Service - Referral form Care-coordinator- Date of referral: Details of referral- Forename: Surname: (Previous Surname __________________________) Address: Postcode:______________ Please tick For No Abode Home Number: Mobile number: Can we leave a message on number/s provided? Yes No Preferred method of contact: Home phone Mobile Phone Text Letter No Preference Date of Birth: Age: Gender: Male Female Transgender Local authority of Residence: Medway Other (please state) _______________ Nationality: Religion: Baha’i Buddhist Christian Hindu Jain Jewish Muslim Pagan Sikh Zoroastrian Declines to disclose Religion Unknown None Sexuality (Please tick) Bisexual Heterosexual Homosexual Not disclosed Other Ethnic group: (Circle one) Currently registered with GP: Yes No GP Name & Surgery details: A White British E & Black African K Bangladeshi R Chinese B White Irish F White & Asian L Other Asian S Other C Other White G Other Mixed M Caribbean Z Not stated D White & Black Caribbean H Indian N African Insert code here: J Pakistani P Other black Name Of Referrer: How did you hear about the service? Referral Organisation: Contact details of referrer: Referral Organisation Further Details: (please tick) ATR – Community Rehabilitation Company ATR – National Probation Service DRR – Community Rehabilitation Company DRR – National Probation Service Voluntary (Self) – Community Rehab. Company Voluntary (Self) – National Probation Service Family Drug & Alcohol Email Address of referrer: Please tick to confirm consent has been given to make referral Reason for referral and other information please add any background you think may be useful ( additional sheets if necessary): Drug and/or Alcohol use: (Please state substances used in the last three months): Please add relevant details I.e. frequency, amounts used : Alcohol units per day- Drinking days in the last 28 days: Injecting status- Injected in last 28 days Currently sharing Ever shared Previously injected (not now) Never injected Declined to answer
Date: .............................................................................................................................
Referrer should take a full history and observe a feed Baby Yes No Mother Yes No Difficulty in latching Squashed/wedged nipple Clicking noises whilst feeding Nipple pain during feed Fussiness at breast Sore damaged nipples Prolonged/frequent feeding Mastitis/breast infections Prolonged physiological jaundice Exhaustion from frequent feeds Frequently coming of the breast or slipping back to the nipple Psychological effects from difficulty in establishing breastfeeding Excessive early weight loss/gain Please specify Family history of blood/ clotting disorders Has Vitamin K been Any additional information (to be completed by referrer) Ethnicity – Please Tick J. Pakistani A. White – British K. Bangladeshi B. White – Irish L. Any other Asian Background C. – Other M. Caribbean D. Mixed – White and Black Caribbean N. African E. – White and Black African P. Any other Black Background F. Mixed – White and Asian R. Chinese G. Mixed – And others S. Any other Ethnic Group H. Indian Z. Not stated Date referral forwarded to CSH Surrey: 2
Please provide details of all people resident in the household: Names of family: Gender: M / F Date of Birth Asylum Seeker √ Refugee √ Considered to be disabled? (by self / main √ Ethnicity? (See Codes below) Child Protection Plan? Y/ N Child in need? Y / N Early Help Assessment or assessment? Y/N Adults that live with the children Mother/ partner: Father/ partner: Other adult(s) living in household: (e.g. grandparent) Children incl surname Children - Eldest to youngest please c1. c2. c3. c4. c5. c6. Asian / Asian British: White: Black/ British: Ethnic Background: Indian = I Pakistani = P Bangladeshi= B Chinese = C Asian Other = AO British = WB Irish= WI White Other = WO Travellers = T African = BA Caribbean= BC Black Other = BO White/BlackAfrican= MB White/Black Caribbean: MC White and Asian: MA Mixed Other: MO FAMILY NEEDS So that we can offer the family the most appropriate support please complete the following table. Please note that there is not a ‘points’ system. Families will not be prioritised on
Is this pupil in the process of EHCP assessment? Has an application been submitted? Is so what date was this/assigned statutory link person? EHCP pupil: What is the EHCP for/main need? How many hours/provison is assigned to the pupil? Who from the Statutory team is aware of this referral? YOU MUST INCLUDE THE EHCP IN THE EVIDENCE FOR APPLICATION YES / NO When was the pupils last annual review? YOU MUST INCLUDE THIS IN THE EVIDENCE FOR APPLICATION Looked After Pupil ALL LOOKED AFTER PUPILS WILL REQUIRE A PROFESSIONALS MEETING AT THE TIME OF APPLICATION YES / NO Responsible authority: Social worker: Contact details: What agencies have been involved with this pupil? Emotional Health and Wellbeing Service Child Development Centre Speech and Language Team Youth Offending Team EYPDAS Visual Impairement Team Educational Psychologist School CAPI YCT/Counselling YOU MUST INCLUDE ALL CONTACT DETAILS: FURTHER PUPIL INFORMATION Is there now, or has there ever been any involvement of Children’s Social Care with this pupil or pupil’s family? Or any concerns? YES / NO Child in Need or child protection When? Who? Contact details (telephone numbers and emails): Has there been any involvement with this pupil or pupil’s family from statutory or non-statutory agencies (e.g. MST, Family Solutions, Family Mosaic, IAG) YES / NO Contact details: Has the pupil had involvement with the police? Received a criminal conviction or caution? If so when and what for. BEHAVIOURS Behaviour data
Care Recipient 1 Care recipient’s relationship to carer Care recipient’s age Is care recipient living with Care recipient’s postcode Care Recipient Condition (Tick all that apply) aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with Care recipient’s postcode: Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis Signature of person completing form Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and assessment for counselling services and inclusion in de-identified data reporting. I understand that Carers Victoria may contact me in relation to this referral and conduct further assessment. Further information on Carers Victoria’s Privacy Policy is available at Signature of carer Or verbal consent obtained by: Name Date of verbal consent Mail to: Carers Cottage Carers Victoria PO Box 2204 FOOTSCRAY VIC 3011 Fax to: (03) 9396 9595 Email: For referral enquiries call Carer Advisory Line on 1800 242 636
CLIENT INFORMATION (please complete ALL sections in full) Date of referral (dd / mm / yyyy): Do you have the client’s consent to refer?: Yes No (Mr, Mrs, Miss, Ms, Dr, etc): First Name: Surname: Gender Male Female Date of Birth: Age: Ethnic Origin of Client: (ie. White British, Asian Indian) Email address: Telephone No: Mobile No: Address (inc post code): Do you get direct payments? What would you like to do? How many hours of support/week would you like? REFERRER INFORMATION (please complete ALL sections in full) Is this a self referral? (if no please complete this section) Title (Mr, Mrs, Miss, Ms, Dr, etc): First Name: Surname: Profession: Telephone No: Mobile No: Email address:
Child’s Name: First Last Birthdate: Medicaid/DHSS Cares# Address: (required) City/State/Zip Home Phone #: (required) County: Sex: Male Female Child’s Ethnicity: Hispanic or Latino Not Hispanic or Latino Child’s Race (CHECK ALL THAT APPLY): White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander School District Primary Language Mother’s Name (required) MCI# Birth Date Email Address Phone #(H) (CELL) (W) Father’s Name MCI# Birth Date Email Address (if different than client’s) Phone #(H) (CELL) (W) Guardian/Foster Parent/Educational Surrogate Name Address Phone #(H) (CELL) (W) Birth Weight Current Weight Gestation APGARS PCP/Office Phone # Fax # ICD10 Insurance Information Private Insurance Co. Name: Policy Holder: Mom Dad (MUST include DOB above) # Member ID# Effective Date: Address: # IF DELAWARE MEDICAID ONLY - CHECK BELOW: MA-Fee For Service/traditional MA-Highmark Health Options MA-United Healthcare Notes: Child Care Name Address Phone# REFERRING AGENCY/PERSON # Email: PEDS Screener ASQ MCHAT Other screening (please specify): RECEIVING AGENCY ACTION DATE Reason for referral:
Referral Information required by Contact Centre The following information is what the Contact Centre will need when a referral is made. This information can be taken over the phone. Social Worker: Tel: Team Manager: Tel: Contact Co-ordinator : Tel: Name of Child(ren) DOB Gender M F Ethnicity Language Legal Status Please state any health needs or disability that any of the child have that a contact supervision or contact venue would need to know Education: School or Years Setting attended Address Phone number Contact Person Current Placement Name Address Phone number Relationship to child Who is the link worker for the care givers? Details of people having contact: Name Address DOB Phone Number Relationship to child
Referral / Admission Request Form Youth Information Basics: Name: Date of Birth: Age: Status Card: ☐Yes ☐No ☐Pending Status in Care: ☐Crown Ward ☐CCA ☐Other: Support for Placement: ☐ Child supports this placement ☐ Parent supports placement ☐ Unknown Placing Agency Information: Unit: Supervisor: Supervisor Email: Phone: Ext: Fax: CSW: CSW Email: Phone: Ext: Fax: FSW: FSW Email: Phone: Ext: Fax: Guardians: Is initial contact allowed? Are there special circumstances? If a parent is deceased, please mark deceased in the phone area provided: Mother: ☐Contact Phone: Father: ☐Contact Phone: Other: ☐Contact Phone: Other: ☐Contact Phone: Notes: Legal Conditions?: ☐ On Probation ☐ Pending Court Community Hours: PO Officer: PO Officer Email: Ext: Fax:
Bristol Communication Aid Service / Dame Hannah Rogers Trust Referral Form Name: Address (inc postcode): Telephone: Email: Clinical Commissioning: Client Details Name: Date of Birth: Address (inc postcode): 5 Telephone: Email: NHS number: Next of kin name: Address(es): (if different from above) Telephone: School/Pre-school: Address: Telephone: Is the person able to travel to BCAS? (NB, home/school visits will only be considered in exceptional circumstances) Yes No Is the person’s language English? Yes No Do the family require an interpreter? Yes No If yes what language? Days available for appointments: (referrer & client) For Adult referrals only: Does the person require hospital transport? Will an escort be accompanying the person? Yes No Make and of wheelchair used for travel if appropriate: Other professionals involved (including GP & Paediatrician): Name Professional Address Tel Number Medical Diagnosis: SLT Diagnosis:
Date of Referral: Is client aware of referral? Yes No Referral Type: Walk in Email Fax Referral Source: Self Doctor: _________________________ School Friend/Family Member Service Provider: __________________________ Client Details Name: Date of Birth: Address: Place of Birth: Suburb: Gender: Male Gender Diverse Unsure Female Mobile: Ethnicity: Health Care Card No: Expiry: Medicare No: Reference: Expiry: Do you suffer from any of the following health conditions? Diabetes Heart Disease Epilepsy Lung Disease Allergies: ______________________ Kidney Disease Arthritis Asthma Low/high Blood Pressure ________________________________________________________________________________ Emergency Contact Details Name: Phone: Address: Email: Relationship: Can we contact this person about your appointments? Yes No Referrer’s Details Referrer’s Details: Same details as Emergency Contact Name: Relationship: Address: Organisation: Email: Can we contact this person about your appointments? Yes No Reason/s for Referral: Mental Health Drugs and Alcohol School/Work General Health What has prompted you to make contact with headspace? Example : feeling stressed and anxious. PLEASE COMPLETE BOTH SIDES OF THIS FORM
Aggression (verbal or physical) Motivation Tendency to worry/fearful/nervous Planning/Organization Unhappy Self-Esteem Withdrawn/Social Isolation Other: Student Attendance: Current Year Absent: Tardy: Previous Year(s) Absent: Recent Academic Assessments Reading (NWEA, DRA, Dibels, QRI, SRI, Running Record, etc.) Name of Assessment Date Administered Score Grade Level At Grade Level Grade Level Writing (AIMsweb, Lucy Calkins rubrics, writing probes, etc.) Name of Assessment Date Administered Below Grade Level At Grade Level Above Grade Level
South Gloucestershire Arts & Libraries Project Creative Arts Courses & Creative Cafe Name DOB Postcode Landline* Mobile* Who we should contact in an emergency – a family member, friend, professional Name: Telephone number: Relationship: Please tell us sessions you would like to attend: Creative Arts Course – Remapping Your Life Patchway Library, Tuesdays 6.30pm – 8.00pm Staple Hill Library, Fridays 10.30am – 12noon Creative Café – welcoming people and those with memory loss Patchway Library, Tuesdays 1.30pm – 3.00pm Staple Hill Library, Fridays 1.30pm – 3.00pm How did you hear the project? Please tell us anything you feel might be useful for us to know about you and your participation in this project: Do you have any access needs that we should know about? Please turn over . . . About us and the way that we work The project team is: Scott Farlow & Matthew Hemson – Lead Artists Donna Baber, Project Manager
(If self, write “self”) Mobile: Personal Details Names of Client/Applicant: Gender: Date of National insurance number: Next of Kin: Email address: Contact number: Country of origin: Are you eligible for housing benefit? yes If you answered no, please give details: Current housing situation Sleeping rough: Social housing: Private rent: Hostel: Facing eviction: If so, when is your eviction? Sofa surfing: Long stay hospital: Family home: Prison: Other (give details): Where are you currently located – address/site/town Skills and Qualifications – briefly tell us about your most recent job, your skills, what you enjoy doing and your ambitions for the future.