For office use only we help you call the shots cir health.nyc.gov .nyc.gov/health/cir child or individual enrollment or update form (1) complete this form. (2) attach a clear copy of your childs or individual applicants lifetime health record or...
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Childhood immunization record my child's name is my child's birthday is my child's doctor is the doctor's phone number is age immunization dose birth hepatitis b (hepb) 1 of 3 2 months diphtheria, tetanus, and pertussis (dtap) 1 of 5 haemophilus...
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Federal register / vol. 76, no. 209 / friday, october 28, 2011 / notices environmental protection agency frl94842 childrens health protection advisory committee (chpac); notice of charter renewal environmental protection agency (epa). action:...
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Commuter student immunization record rev. 3 (20120426) not confidential immunization records are not confidential as required by law name: male last first female middle m m d d y y y y student id: date of birth: to be completed and signed by a...
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Name: health & wellness center 285 pawling avenue, troy new york 12180 (518) 833-1505, fax (518) 833-1835 birthdate: immunization record to be completed by student s healthcare provider this record is required to be submitted annually for all...
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Checklist for preparingfor the interviewdoing your beston yourjobinterviewpersonneldepartmentcity of los angelesread this pamphlet carefully.make a list of your good points and think of concreteexamples that demonstrate them.practice answering the...
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Proof of measles immunity for employment if you were born on or before 1/1/1957 you do not need to complete this form. name: dob: department: w# please provide one of the following along with this completed form: ? a copy of a medical provider...
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Office use only initials date entered in iris billed cedar county public health 400 cedar st. tipton, ia 886(563) 8866 child 2014/2015 influenza vaccine consent form & administration recordchild section 1 name: (last) (first) (mi) box#: address:...
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Influenza vaccine consent form and administration record personal information (please print) name: birthdate: age: address: sex: m f city: state: zip: i have read or have had explained to me the vaccine information statement about influenza and...
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Vaccination exemption pursuant to the official code of georgia annotated 20-2-771 4. (e) this code section shall not apply to a child whose parent or legal guardian objects to immunization of the child on the grounds that the immunization...
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Kiphs # encounter # h1n1 vaccine consent form & administration record (revised 11/18/09) please fill out this section last information about the person to receive the vaccination (please print) first mi birth date age address city phone number...
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2015 event order form valid from 1st january 31st december 2015 internet connection (lan) quantity cost internet access (from 1 mbps) for 1 device via the excel london lan we provide: 1 x 10/100/1 ethernet connection (rj45 male termination; 1 x...
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Final total maximum daily loads of fecal bacteria for the herring run basin in baltimore city and baltimore county, maryland final department of the environment montgomery business park center 1800 washington boulevard, suite 540 baltimore md...
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Bring your game to canadas premier multicourt basketball only facility hoopdome summer basketball camp application (boys & girls ages 717) each session runs mf from 9am4pm *session 1: july 5, 2016 *session 3: august 812, 2016 *session 2: july 25...
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In the supreme court of the state of new mexicoaugust 28, 2007no. 078500in the matter of the approval of the2007 annual report of the new mexicocommission on access to justiceorderwhereas, this matter came on for consideration by the court at the...
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