ࡱ > D1 bjbjFF $ $ E a# a# e$ e$ e$ y$ y$ y$ y$ 8 $ M% L y$ xC $ ' S, S, S, S, ~. r . D 4/ $ B B B B B B B E >H B e$ X/ >. @ ~. X/ \/ B `/ a# a# S, S, 2C `/ `/ `/ `/ a# S, e$ S, B `/ X/ B `/ `/ r 9 T $ J e$ 9 A` y$ `/ s9 9 HC 0 xC 9 z H `/ H 9 `/ e$ 9 X/ X/ X/ '" :
Functional Assessment Summary
This supplementary template is sent with referrals that occur following assessment of the clients functional abilities and need for assistance. Theassessing agency may attach additional assessment summaries covering other domains ofclient need that are relevant to the referral.Consumer
Name: FORMTEXT
D a t e o f B i r t h : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T
S e x : F O R M T E X T
U R N u m b e r : F O R M T E X T
o r a f f i x l a b e l h e r e R a t i n g o f F u n c t i o n a l A b i l i t i e s
N o t e s o n r a t i n g s :
T i c k o n e r e s p o n s e f o r e a c h a c t i v i t y ( example: housework, transport, shopping etc.)
Rate what the person is currently capable of doing rather than what they actually do. In addressing capability for any item, take into account not only physical function but also cognition (such as problems caused by dementia or an intellectual disability) and behaviour (such as unpredictable challenging behaviour). People able to complete a task only with verbal prompting should not be rated as independent.
If unable to rate an activity, leave it blank.
Assessment notes: Use the notes section to describe clients specific need for assistance as well as other factors impacting on level and type of need e.g. use of aids and equipment/home modifications; assistance provided by carers/other agencies.
ActivityRating ((one)Domestic Care1. Housework FORMCHECKBOX Can maintain house without help or supervision (including laundry) FORMCHECKBOX Needs some help or supervision FORMCHECKBOX Completely unable to do housework2. Transport FORMCHECKBOX Without help (drives own car, travels independently on public transport or taxis) FORMCHECKBOX With some help (need someone to help or accompany when traveling) FORMCHECKBOX Completely unable to travel (unless arrangements are made for a specialized vehicle like an ambulance)3. Shopping (assuming client has transport) FORMCHECKBOX Can take care of all shopping needs FORMCHECKBOX With some help (need someone to go with client on all shopping trips) FORMCHECKBOX Completely unable to do any shopping4. Meal Preparation FORMCHECKBOX Without help (incl planning/preparing/cooking, adequacy of meals and serving) FORMCHECKBOX With some help FORMCHECKBOX Completely unable to do any meal preparation, serving or manage nutrition5. Taking Medications FORMCHECKBOX Without help (in the right doses at the right time) FORMCHECKBOX With some help (e.g. if someone prepares or reminds client) FORMCHECKBOX Completely unable to take own medicines without help6. Handling Money FORMCHECKBOX Without help (writing cheques, paying bills, banking, keeping track of finances) FORMCHECKBOX With some help (manage day-to-day buying but need help with chequebook and paying bills) FORMCHECKBOX Completely unable to handle money7. Telephone FORMCHECKBOX Without help (making and receiving phone calls & incl use of assistive devices) FORMCHECKBOX With some help FORMCHECKBOX Completely unable to use the telephone8. Mobility/Walking FORMCHECKBOX Without help, except for the use of a cane FORMCHECKBOX With some help from a person (physical or verbal), or with the use of a walker or crutches. If in a wheelchair, tick this rating if the person manages independently including cornering. FORMCHECKBOX Completely unable to walk. If in a wheelchair, tick this rating if the person is not independent but must be pushed.9. Mobility: bed/chair transfers FORMCHECKBOX No help needed FORMCHECKBOX Needs some help F O R M C H E C K B O X U n a b l e t o m a n a g e n o s i t t i n g b a l a n c e A s s e s s m e n t n o t e s D o m e s t i c C a r e : F O R M T E X T
P r o d u c e d b y t h e V i c t o r i a n D e p a r t m e n t o f H u m a n S e r v i c e s , 2 0 0 9 T h i s i n f o r m a t i o n c o l l e c t e d b y : S u p p l e m e n t a r y F o r m P a g e 1 o f 2 N a m e : F O R M T E X T P o s i t i o n / A g e n c y : F O R M T E X T S i g n : D a t e : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T C o n t a c t n u m b e r : F O R M T E X T
F u n c t i o n a l A s s e s s m e n t S u m m a r y
T h i s s u p p l e m e n t a r y t e m p l a t e i s s e n t w i t h r e f e r r a ls/ feedback that occur following assessment of the clients functional abilities and need for assistance. The assessing agency may attach additional assessment summaries covering other domains of client need that are relevant to the referral.Consumer
Name: FORMTEXT
D a t e o f B i r t h : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T
S e x : F O R M T E X T
U R N u m b e r : F O R M T E X T
o r a f f i x l a b e l h e r e
A c t i v i t y R a t i n g
( ( o n e ) P e r s o n a l C a r e 1 0 . S e l f - c a r e s c r e e n i n g q u e s t i o n D o e s t h e c l i ent need assistance with any areas of personal care/self care, such as bathing, dressing, eating toileting, managing incontinence? FORMCHECKBOX No (( skip the personal care items and go to Q16) FORMCHECKBOX Yes (( proceed to the following personal care items)11. Bathing FORMCHECKBOX Without help (include in and out of shower or bath and washing unsupervised) FORMCHECKBOX With some help (e.g. need help getting in or out of the bath) FORMCHECKBOX Completely unable to bathe without help12. Dressing FORMCHECKBOX Without help (incl buttons, zips, laces) FORMCHECKBOX With some help (e.g. help with buttons etc. but can put on some garments alone) FORMCHECKBOX Completely unable to dress13. Eating FORMCHECKBOX Without help FORMCHECKBOX With some help (e.g. help cutting up food, spreading butter, pouring drink) FORMCHECKBOX Completely unable to eat without help (e.g. spoon feeding)14. Toilet use FORMCHECKBOX Without help (includes on and off, dressing and cleans self) FORMCHECKBOX With some help FORMCHECKBOX Completely unable to manage toiletting without help15. Continence (bowels and/or bladder) FORMCHECKBOX Completely continent including self management of catheter or ostomy. Rate based on last week. FORMCHECKBOX Occasional incontinence (less than once per day) FORMCHECKBOX Incontinent (no control or daily episodes of incontinence)Assessment notes Personal Care/Self Care: FORMTEXT A c t i v i t y R a t i n g
( ( o n e ) C o m m u n i c a t i o n , C o g n i t i o n & B e h a v i o u r 1 6 . C o m m u n i c a t i o n ( N e e d f o r a s s i s t a n c e w i t h u n d e r s t a n d i n g o r m a k i n g o n e s e l f u n d e r s t o o d b y o t h e r s ) F O R M C H E C K B O X N o a s s i s t a n c e r e q u i r e d i n c l u d i n g i n d e p e n d e n t u s e o f a i d s a n d e q u i p m e n t such as hearing aids or speech aids. Do not indicate use of interpreters here. FORMCHECKBOX Some assistance required (e.g. if person sometimes or often misses the speakers intent, or needs prompting to find words or finish sentences.) FORMCHECKBOX Assistance always requiredAssessment notes Communication: FORMTEXT 1 7 . M e m o r y p r o b l e m s o r c o n f u s i o n F O R M C H E C K B O X N o F O R M C H E C K B O X Y e s 1 8 . B e h a v i o u r a l p r o b l e m s F O R M C H E C K B O X N o F O R M C H E C K B O X Y e s ( e . g . a g g r e s s i o n , w a n d e r i n g o r a g i t a t i o n ) A s s e s s m e n t n o t e s C o g n i t i o n a n d B e h a v i o u r : F O R M T E X T A s s e s s m e n t d e t a i l s
D a t e o f a s s e s s m e n t : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T A s s e s s o r N a m e : F O R M T E X T
O t h e r c o m m e n t s , e . g . a s s e s s m e n t t o o l s u s e d , l o c a t i o n o f a s s e s s m e n t , o t h e r a s s e s s m e n t s u m m a r i e s a t t a c h e d :
F O R M T E X T
P r o d u c e d b y t h e V i c t o r i a n D e p a r t m e n t o f H u m a n S e r v i c e s , 2 0 0 9 T h i s i n f o r m a t i o n c o l l e c t e d b y : S u p p l e m e n t a r y F o r m P a g e 2 o f 2 N a m e : F O R M T E X T P o s i t i o n / A g e n c y : F O R M T E X T S i g n : D a t e : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T C o n t a c t n u m b e r : F O R M T E X T
F u n c t i o n a l A s s e s s m e n t S u m m a r y
F u n c t i o n a l A s s e s s m e n t S u m m a r y
9 : I J T U
*
,
D
F
Z
\
d
n
p
( R
v hiP 5B*CJ _H ph hiP 5CJ _H hiP 6 hiP 5hiP jB hiP U_H j hiP U_H jb hiP U_H j hiP U_H jv hiP U_H
hiP 5_H j hiP U_H j hiP U_H
hiP _H - 8 9 C
* R $ $If a$l ; $If l 9 $If l $If l $If l $If l R T .
R L J H H D : < : x < kd $$If l F d' d %
t
0 ' 2q 2 l 2 2q 4 4
l al p
$d8 $If a$l d8 $If l dB < % & 4 5 6 z { | } U V W ǶǟǗǶǀǗǶiǗǶRǗ,j hiP hiP B*CJ U_H ph ,j^ hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph hiP B*ph ,j hiP hiP B*CJ U_H ph j hiP B*CJ U_H ph hiP B*CJ _H ph hiP 5B*ph hiP 5B*CJ _H ph ( j hiP 5B*CJ OJ QJ _H ph % 7 z S > & > $d8 $If a$l d8 $If l kd $$If l F
' 0 ' 4 4
l al p z { | w b J b $d8 $If a$l d8 $If l kdD $$If l 4 Z F
'` 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al U y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al U V W i y d L d $d8 $If a$l d8 $If l kd% $$If l 4 F
'` 0 ' 4 4
l al W X f g h & ' S T b c d e w` ,j hiP hiP B*CJ U_H ph ,j
hiP hiP B*CJ U_H ph hiP CJ _H ,jH hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph hiP B*ph ,j hiP hiP B*CJ U_H ph hiP B*CJ _H ph j hiP B*CJ U_H ph % & y d L d $d8 $If a$l d8 $If l kd\
$$If l 4 F
' 0 ' 4 4
l al & ' S e y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
'` 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kd
$$If l 4 F
' 0 ' 4 4
l al 1 C y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al 1 2 @ A B C ) * 8 9 : ; o p q r ûûûvû_ ,j hiP hiP B*CJ U_H ph ,jv hiP hiP B*CJ U_H ph ,j? hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph hiP B*ph hiP CJ _H ,j hiP hiP B*CJ U_H ph j hiP B*CJ U_H ph hiP B*CJ _H ph % y d L d $d8 $If a$l d8 $If l kdS $$If l 4 F
'` 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al ) ; o y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al o p q y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
'` 0 ' 4 4
l al * + , - ~ ! " / 0 > v ,jm hiP hiP B*CJ U_H ph ,jD hiP hiP B*CJ U_H ph ,j
hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph j hiP B*CJ U_H ph hiP B*ph hiP CJ _H hiP B*CJ _H ph & y d L d $d8 $If a$l d8 $If l kd! $$If l 4 F
' 0 ' 4 4
l al - ~ y d L d $d8 $If a$l d8 $If l kdJ $$If l 4 F
' 0 ' 4 4
l al ~ y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
'` 0 ' 4 4
l al ! y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al ! " / A y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al > ? @ A A B C D R S T ļ̥ļ̎ļw̼`̼ ,jr hiP hiP B*CJ U_H ph ,j; hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph hiP B*ph hiP CJ _H hiP B*CJ _H ph j hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph % y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
'` 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kdO $$If l 4 F
' 0 ' 4 4
l al A y d L d $d8 $If a$l d8 $If l kdx $$If l 4 F
' 0 ' 4 4
l al A B C U y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
'` 0 ' 4 4
l al # y d L d $d8 $If a$l d8 $If l kd $$If l 4 F
' 0 ' 4 4
l al ! " " $ r t ~p\ &jw% hiP B*CJ U_H ph hiP 5B*CJ _H ph ,j@$ hiP hiP B*CJ U_H ph ,j # hiP hiP B*CJ U_H ph ,j! hiP hiP B*CJ U_H ph hiP B*ph j hiP B*CJ U_H ph ,j hiP hiP B*CJ U_H ph hiP B*CJ _H ph y d L d $d8 $If a$l d8 $If l kd! $$If l 4 F
' 0 ' 4 4
l al y d L d $d8 $If a$l d8 $If l kdF" $$If l 4 F
'` 0 ' 4 4
l al & r y d L d $d8 $If a$l d8 $If l kd}# $$If l 4 F
' 0 ' 4 4
l al r t y d d8 $If l kd$ $$If l 4 F
' 0 ' 4 4
l al b d < > R T b d f r t vl_lvlRlvHhiP OJ QJ _H j( hiP U_H jU( hiP U_H j hiP U_H hiP 5OJ QJ _H hiP 0J _H hiP 5CJ OJ QJ mH sH
hiP _H !hiP 5CJ OJ QJ _H mH sH !hiP 5CJ OJ QJ _H mH sH hiP hiP B*ph hiP B*CJ _H ph j hiP B*CJ U_H ph +j hiP B*CJ U_H mH nH ph u b m ] $ $If l $
r U" $If a$l
9r $If l b kd% $$If l ' ' 0 ' 4 4
l al b d { k [ % $If l # $If l kd& $$If l F ' 0 '6 4
l al d o _ _ " $If l kd\' $$If l 0 ' 0 '6 2 4
l al p d f t ` k [ [ [ " $If l kdA) $$If l 0 ' 0 '6 2 U 2 4
l al p t 8 : N P ^ ` b d * , D F Z \ d n p 𧙕t j- hiP U_H
hiP 5_H jI- hiP U_H hiP hiP CJ OJ QJ mH sH hiP OJ QJ _H j+ hiP U_H hiP 5OJ QJ _H j5+ hiP U_H j* hiP U_H jI* hiP U_H j hiP U_H
hiP _H )` b d M K ; + $If l $If l kd, $$If l F '
0 '6 2 U 2 4
l al p * R $ $If a$l ; $If l 9 $If l $If l ( R V x z ⷩ~vp_ j hiP B*CJ U_H ph
hiP CJ hiP CJ _H hiP B*CJ ph hiP B*CJ _H ph ( j hiP 5B*CJ OJ QJ _H ph hiP 5B*CJ _H ph hiP j/ hiP U_H j/ hiP U_H j. hiP U_H
hiP _H j hiP U_H j5. hiP U_H R T V h R P ; d8 $If l kd0 $$If l F d' d %
t
0 ' 2q 2 l 2 2q 4 4
l al p
h v & kd 1 $$If l F
' 0 ' 4 4
l al p d8 $If l $d8 $If a$l u ] $d8 $If a$l u kd2 $$If l 4 0 '` 0 ' 4 4
l al d8 $If l ! ! ! ! .! /! 0! 1! ~! ! ! ! ! ! ! ! ! ! ! ! ! ̷̷̠̽̽̉́j́ ,j6 hiP hiP B*CJ U_H ph hiP CJ _H ,jD5 hiP hiP B*CJ U_H ph ,j4 hiP hiP B*CJ U_H ph
hiP CJ j hiP B*CJ _H ph hiP B*CJ _H ph j hiP B*CJ U_H ph ,j2 hiP hiP B*CJ U_H ph " ! w b J b $d8 $If a$l d8 $If l kd@3 $$If l 4 F
' 0 ' 4 4
l al ! ! ! 1! ~! w b J b $d8 $If a$l d8 $If l kd|4 $$If l 4 F
' 0 ' 4 4
l al ~! ! ! ! ! w b J b $d8 $If a$l d8 $If l kd5 $$If l 4 F
'` 0 ' 4 4
l al ! ! ! ! " w b J b $d8 $If a$l d8 $If l kd6 $$If l 4 F
' 0 ' 4 4
l al ! ! ! ! "
" " " )" *" +" U" V" W" X" f" g" h" " " " " " " " " " " " # # # # # # ļ̝̝̌̆o̝X̝ ,j< hiP hiP B*CJ U_H ph ,jF; hiP hiP B*CJ U_H ph ,j: hiP hiP B*CJ U_H ph hiP B*CJ ph ,j8 hiP hiP B*CJ U_H ph
hiP CJ hiP CJ _H hiP B*CJ _H ph j hiP B*CJ U_H ph ,j7 hiP hiP B*CJ U_H ph " "
" " ," U" w b J b $d8 $If a$l d8 $If l kd"8 $$If l 4 F
' 0 ' 4 4
l al U" V" W" i" " w b J b $d8 $If a$l d8 $If l kd^9 $$If l 4 F
'` 0 ' 4 4
l al " " " " " w b J b $d8 $If a$l d8 $If l kd: $$If l 4 F
' 0 ' 4 4
l al " " " # # w b J b $d8 $If a$l d8 $If l kd; $$If l 4 F
' 0 ' 4 4
l al # # # (# t# w b J b $d8 $If a$l d8 $If l kd< $$If l 4 F
'` 0 ' 4 4
l al # # %# &# '# t# u# v# w# # # # # # # # # # # "$ #$ $$ %$ 3$ 4$ 5$ F$ G$ H$ I$ W$ X$ Y$ $ $ $ $ $ }f ,jB hiP hiP B*CJ U_H ph ,jdA hiP hiP B*CJ U_H ph ,j(@ hiP hiP B*CJ U_H ph ,j> hiP hiP B*CJ U_H ph hiP B*CJ ph ,j= hiP hiP B*CJ U_H ph hiP B*CJ _H ph j hiP B*CJ U_H ph %t# u# v# # # w b J b $d8 $If a$l d8 $If l kd2> $$If l 4 F
' 0 ' 4 4
l al # # # # "$ w b J b $d8 $If a$l d8 $If l kd`? $$If l 4 F
' 0 ' 4 4
l al "$ #$ $$ 6$ F$ w b J b $d8 $If a$l d8 $If l kd@ $$If l 4 F
'` 0 ' 4 4
l al F$ G$ H$ Z$ $ w b J b $d8 $If a$l d8 $If l kdA $$If l 4 F
' 0 ' 4 4
l al $ $ $ $ '% w b J b $d8 $If a$l d8 $If l kdC $$If l 4 F
' 0 ' 4 4
l al $ $ $ '% (% )% *% 8% 9% :% l% m% n% o% }% ~% % % % % % % % % &
& & & & 2& ̫̔r\ +j hiP B*CJ U_H mH nH ph u&jtG hiP B*CJ U_H ph hiP 5B*CJ _H ph ,j8F hiP hiP B*CJ U_H ph ,j
E hiP hiP B*CJ U_H ph hiP B*CJ ph hiP B*CJ _H ph j hiP B*CJ U_H ph ,jC hiP hiP B*CJ U_H ph '% (% )% ;% l% w b J b $d8 $If a$l d8 $If l kdBD $$If l 4 F
'` 0 ' 4 4
l al l% m% n% % % w b J b $d8 $If a$l d8 $If l kd~E $$If l 4 F
' 0 ' 4 4
l al % % & w b d8 $If l kdF $$If l 4 F
' 0 ' 4 4
l al & & "& 0& @& & o o $d8 $If a$l d8 $If l b kdG $$If l 7 ' ' 0 ' 4 4
l al 2& 4& & & & & P' R' T' p' r' t' ' P( Q( R( S( T( b( c( d( ( ( ( ( ) ) ) $) %) F) G) H) R) S) ѰљѰтѰkѰW&j M hiP B*CJ U_H ph ,jK hiP hiP B*CJ U_H ph ,jJ hiP hiP B*CJ U_H ph ,jI hiP hiP B*CJ U_H ph j hiP B*CJ U_H ph hiP CJ _H hiP B*ph hiP B*CJ _H ph hiP 5B*CJ _H ph ( j hiP 5B*CJ OJ QJ _H ph "& & R' v' Q( S > & > $d8 $If a$l d8 $If l kdH $$If l F
' 0 ' 4 4
l al p Q( R( S( e( ( w b J b $d8 $If a$l d8 $If l kdI $$If l 4 F
'` 0 ' 4 4
l al ( ( ( ) $) w b J b $d8 $If a$l d8 $If l kd'K $$If l 4 F
' 0 ' 4 4
l al $) %) * w b d8 $If l kdUL $$If l 4 F
' 0 ' 4 4
l al S) *
* * * * R* T* p* r* t* ~* * * * * * * * * * * + + + + + + + 0+ 2+ 4+ + + + + ͮ͗̀i[ hiP 5B*CJ _H ph ,jQ hiP hiP B*CJ U_H ph ,jP hiP hiP B*CJ U_H ph ,jgO hiP hiP B*CJ U_H ph ,j+N hiP hiP B*CJ U_H ph hiP B*ph hiP B*CJ _H ph +j hiP B*CJ U_H mH nH ph u j hiP B*CJ U_H ph #* * R* v* ~* o $d8 $If a$l d8 $If l b kdM $$If l 7 ' ' 0 ' 4 4
l al ~* * * * * w b J b $d8 $If a$l d8 $If l kdN $$If l 4 F
'` 0 ' 4 4
l al * * * + + w b J b $d8 $If a$l d8 $If l kdO $$If l 4 F
' 0 ' 4 4
l al + + + 6+ + w b J b $d8 $If a$l d8 $If l kdQ $$If l 4 F
'` 0 ' 4 4
l al + + , w b d8 $If l kdSR $$If l 4 F
' 0 ' 4 4
l al + + , , , , , , , |, ~, , , , , , , , , , , , , , , , , , , , , - - &- (- 㱭viY jU hiP B*Uph j hiP B*Uph jU hiP UjT hiP Uj hiP UmH nH u j)T hiP Uj hiP UhiP hiP B*ph +j hiP B*CJ U_H mH nH ph u&jS hiP B*CJ U_H ph hiP B*CJ _H ph j hiP B*CJ U_H ph ", , <, 8-
. 2. 4. 6. j W B @ x &d (d P R &d (d P R < &d (d P R
&d (d P R b kdS $$If l 7 ' ' 0 ' 4 4
l al (- *- 4- 6- 8-
. . . ". $. .. 0. 6. 8. :. . . $/ 0/ 2/ 4/ B/ D/ X/ Z/ h/ j/ / / / ʹգ}uj}`S`j` j7X hiP U_H j hiP U_H hiP 5OJ QJ _H hiP 0J _H hiP 5CJ OJ QJ mH sH
hiP _H !hiP 5CJ OJ QJ _H mH sH !hiP 5CJ OJ QJ _H mH sH j hiP UmH nH u jU hiP Uj hiP UhiP hiP B*ph #j hiP B*UmH nH ph uj hiP B*Uph 6. 8. :. . . . > . # $If l kdgV $$If l F ' 0 '6 4
l al $ $If l $
r U" $If a$l
9r $If l . 2/ 4/ j/ / _ O O " $If l kd>W $$If l 0 ' 0 '6 2 4
l al p % $If l / / / / / / / / / 0 0 0 0 0 00 20 :0 B0 D0 X0 Z0 f0 h0 0 0 0 0 0 0 0 0 0 0 1 <1 D1 ȾȱȤȗȊ|x nxnx hiP mH nH sH hiP hiP CJ OJ QJ mH sH j[ hiP U_H j[ hiP U_H jZ hiP U_H j+Z hiP U_H hiP OJ QJ _H
hiP _H hiP 5CJ OJ QJ mH sH hiP 5OJ QJ _H j hiP U_H jX hiP U_H #/ / / h0 0 k [ [ [ " $If l kd#Y $$If l 0 ' 0 '6 2 U 2 4
l al p 0 0 0 0 0 0 0 0 0 M K I G I I I I & kd[ $$If l F '
0 '6 2 U 2 4
l al p 0 0 1 <1 >1 @1 B1 D1 & / 0 {. A!n"p#$ % X" ,,
g{ H H ( d h
com.apple.print.PageFormat.FormattingPrinter
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.FormattingPrinter
Acrobat_Distiller_Tancredi_on_localhost
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMHorizontalRes
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMHorizontalRes
300
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T08:50:57Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMOrientation
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMOrientation
1
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMScaling
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMScaling
1
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMVerticalRes
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMVerticalRes
300
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T08:50:57Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMVerticalScaling
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMVerticalScaling
1
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.subTicket.paper_info_ticket
com.apple.print.PageFormat.PMAdjustedPageRect
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMAdjustedPageRect
0.0
0.0
3508.3333333333335
2479.166666666667
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PageFormat.PMAdjustedPaperRect
com.apple.print.ticket.creator
com.apple.printingmanager
com.apple.print.ticket.itemArray
com.apple.print.PageFormat.PMAdjustedPaperRect
0.0
0.0
3508.3333333333335
2479.166666666667
com.apple.print.ticket.client
com.apple.printingmanager
com.apple.print.ticket.modDate
2005-10-26T22:33:29Z
com.apple.print.ticket.stateFlag
0
com.apple.print.PaperInfo.PMConstrainedPaper
com.apple.print.ticket.creator
CUPS_CPL
com.apple.print.ticket.itemArray
com.apple.print.PaperInfo.PMConstrainedPaper
com.apple.print.ticket.client
CUPS_CPL
com.apple.print.ticket.modDate
2005-10-26T22:33:28Z
com.apple.print.ticket.stateFlag
1
com.apple.print.PaperInfo.PMPaperName
com.apple.print.ticket.creator
CUPS_CPL
com.apple.print.ticket.itemArray
com.apple.print.PaperInfo.PMPaperName
iso-a4
com.apple.print.ticket.client
CUPS_CPL
com.apple.print.ticket.modDate
2005-10-26T22:33:28Z
com.apple.print.ticket.stateFlag
1
com.apple.print.PaperInfo.PMUnadjustedPageRect
com.apple.print.ticket.creator
CUPS_CPL
com.apple.print.ticket.itemArray
com.apple.print.PaperInfo.PMUnadjustedPageRect
0.0
0.0
842
595
com.apple.print.ticket.client
CUPS_CPL
com.apple.print.ticket.modDate
2005-10-26T22:33:28Z
com.apple.print.ticket.stateFlag
1
com.apple.print.PaperInfo.PMUnadjustedPaperRect
com.apple.print.ticket.creator
CUPS_CPL
com.apple.print.ticket.itemArray
com.apple.print.PaperInfo.PMUnadjustedPaperRect
0.0
0.0
842
595
com.apple.print.ticket.client
CUPS_CPL
com.apple.print.ticket.modDate
2005-10-26T22:33:28Z
com.apple.print.ticket.stateFlag
1
com.apple.print.PaperInfo.ppd.PMPaperName
com.apple.print.ticket.creator
CUPS_CPL
com.apple.print.ticket.itemArray
com.apple.print.PaperInfo.ppd.PMPaperName
A4
com.apple.print.ticket.client
CUPS_CPL
com.apple.print.ticket.modDate
2005-10-26T22:33:28Z
com.apple.print.ticket.stateFlag
1
com.apple.print.ticket.APIVersion
00.20
com.apple.print.ticket.privateLock
com.apple.print.ticket.type
com.apple.print.PaperInfoTicket
com.apple.print.ticket.APIVersion
00.20
com.apple.print.ticket.privateLock
com.apple.print.ticket.type
com.apple.print.PageFormatTicket
v D T e x t 1 8 v D T e x t 6 4 v D T e x t 6 4 j D v D T e x t 2 0 v D T e x t 2 1 $$If l !v h5 d5 5%#v d#v #v%:V l
t
0 '5 d5 5%/ / 2q 2 l 2 2q al p
$$If l !v h5 55 #v #v#v :V l 0 ' , 5 55 / 4 al p t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 4Z 0 ' + 5 55 / / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 /
/ 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 /
/ / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 1 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al v D T e x t 1 0 $$If l !v h5 '#v ':V l 0 ' 5 '/ 4 al $$If l !v h5 55#v #v#v:V l 0 '6 , 5 55/ / 4 al $$If l !v h5 5 #v #v :V l 0 '6 5 5 / / 2 4 al p v D T e x t 1 1 v D T e x t 1 2 $$If l !v h5 5#v #v:V l 0 '6 , 5 5/ / 2 U 2 4 al p v D T e x t 6 4 v D T e x t 6 4 j D v D T e x t 1 5 2$$If l !v h5 5
5 #v #v
#v :V l 0 '6 , 5 5
5 /
/ 2 U 2 4 al p v D T e x t 1 8 v D T e x t 6 4 v D T e x t 6 4 j D v D T e x t 2 0 v D T e x t 2 1 $$If l !v h5 d5 5%#v d#v #v%:V l
t
0 '5 d5 5%/ / 2q 2 l 2 2q al p
$$If l !v h5 55 #v #v#v :V l 0 ' , 5 55 / 4 al p $$If l !v h5 5 #v #v :V l 40 ' + 5 5 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al v D T e x t 1 1 $$If l !v h5 '#v ':V l 70 ' 5 '/ 4 al $$If l !v h5 55 #v #v#v :V l 0 ' , 5 55 4 al p t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al v D T e x t 1 2 $$If l !v h5 '#v ':V l 70 ' 5 '/ 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al t D e C h e c k 2 $$If l !v h5 55 #v #v#v :V l 40 ' + 5 55 / 4 al v D T e x t 1 3 $$If l !v h5 '#v ':V l 70 ' 5 '/ 4 al v D T e x t 6 4 v D T e x t 6 4 j D t D T e x t 6 t D T e x t 9 $$If l !v h5 55#v #v#v:V l 0 '6 , 5 55/ / 4 al $$If l !v h5 5 #v #v :V l 0 '6 5 5 / / 2 4 al p v D T e x t 1 1 v D T e x t 1 2 $$If l !v h5 5#v #v:V l 0 '6 , 5 5/ / 2 U 2 4 al p v D T e x t 6 4 v D T e x t 6 4 j D v D T e x t 1 5 2$$If l !v h5 5
5 #v #v
#v :V l 0 '6 , 5 5
5 /
/ 2 U 2 4 al p < 6 6 6 6 6 6 6 6 6 v v v v v v v v v 6 6 6 6 6 6 8 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 h H 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 2 0 @ P ` p 2 ( 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 8 X V ~ _HmH nH sH tH @ ` @ N o r m a l OJ QJ _HmH sH tH L @ L H e a d i n g 1 $@& 5B*CJ< OJ QJ ph D @ D H e a d i n g 4 $$@&a$
5>*CJ ^ @ ^ H e a d i n g 7 ) $$e1$ 5$ 7$ 8$ 9D @&H$ ^ea$ 5CJ : @ : H e a d i n g 9
< @& D A` D D e f a u l t P a r a g r a p h F o n t Z i@ Z T a b l e N o r m a l :V 4
l 4 a _H ( k` ( N o L i s t ` o ` A H e a d i n g A d # CJ, OJ QJ _HmH nH sH tH u J O J
D H S T e x t 1 0 p t 1$ 5$ 7$ 8$ 9D H$ N O N
D H S T e x t 1 2 p t 1$ 5$ 7$ 8$ 9D H$ CJ X o"X A M a i n S u b h e a d OJ QJ _HmH nH sH tH u B O B D H S R e p o r t H d 2 5CJ j oBj A C o n s u m e r H e a d d, < & 5CJ OJ QJ _HmH nH sH tH ud oRd A C o n s u m e r t e x t d < OJ QJ _HmH nH sH tH u < O b< t a b l e B*CJ OJ QJ ph b "@ b C a p t i o n dT d 7$ 8$ H$ B*CJ OJ QJ mH ph sH u d od A H e a d i n g B dT d # CJ OJ QJ _HmH nH sH tH u b ob A B o d y t e x t d < 7$ 8$ H$ CJ OJ QJ _HmH sH tH > P@ > B o d y T e x t 2 6OJ QJ p op A T a b l e h e a d i n g d 7$ 8$ H$ % B*CJ OJ QJ _HmH ph sH tH F @ F F o o t e r 1$ 5$ 7$ 8$ 9D H$
9r . )@ . P a g e N u m b e r 4 @ 4 H e a d e r
! r or A s m a l l c a p t i o n
d x & 6CJ OJ QJ _HmH nH sH tH uB OB A B o d y s m a l l d CJ R OR A B o d y s m a l l i n d e n t ! ^ ` H O1"H
A F o o t e r l e f t "
U" 5 l o2l A F o o t e r b o l d l e f t # d8 & 5CJ OJ QJ _HmH nH sH tH uH O1BH A F o o t e r b o l d r i g h t $ $a$ > O!R> A F o o t e r r i g h t % $a$ ` ob` A s i d e t i t l e & $a$& 5CJ OJ QJ _HmH nH sH tH uH OrH A B o d y 5 m m t a b ' ^ ` L @ L C o m m e n t T e x t ( 1$ 5$ 7$ 8$ 9D H$ CJ X oX A B o d y b u l l e t 1 )
& F
^ ` d od D H S H D H e a d i n g * + 5B* CJ& KH _HmH nH ph sH tH u R Q@ R B o d y T e x t 3 + 6B*OJ QJ mH ph sH u \ O \
D H S H e a d i n g 2 , d x 1$ 5$ 7$ 8$ 9D H$ 5CJ @ O@ A H e a d i n g C - $$ 5 L OL A C o d e t e x t . $$ ^ ` @ O@ A H e a d i n g B 1
/ $x ( F OF A C o d e t e x t f i n a l 0 $ x 6 O6 A H e a d i n g D 1 6 L o"L A F o o t e r 2 OJ QJ _HmH nH sH tH u < O < D H S N o t e s 3 d 6CJ B O B D H S R e p o r t H d 3 4 5CJ Z O RZ D H S T e x t B o l d 8 p t 5 1$ 5$ 7$ 8$ 9D H$ 5CJ d o d D H S B u l l e t T e x t ' 6
& F
h x 1$ 5$ 7$ 8$ 9D H$ CJ ` o ` D H S N u m b e r i n g O u t l i n e 7
& F 1$ 5$ 7$ 8$ 9D H$ ^ o^ A D r a f t 8 3 5@,B*CJ< OJ QJ _HmH nH ph sH tH u f O f A C o n s u m e r h e a d s m a l l 9 d 5OJ QJ mH nH u` o` A B o d y s m a l l b u l l e t :
& F
V^ `V h O h A C o n s u m e r t e x t s m a l l ; d CJ OJ QJ mH nH u PK ! K [Content_Types].xmlj0Eжr(] yl#!MB ;BQޏaLSWyҟ^@
Lz]__CdR{`L=r 85v&mQ뉑8IC X=H"Z= &JCjwA`.Â?U~YkG/̷x 3%o3t\&@w! H'"v0 PK ! ֧ 6 _rels/.relsj0 }Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_ 6LR7`0̞O,En7Lib/Se е PK ! ky theme/theme/themeManager.xml M
@}w7c(Ebˮ CAǠҟ7՛K
Y,
e.|,H ,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8 PK ! \ theme/theme/theme1.xmlYOoE# F{o'NDuر i-q;N3'
G$$DA č*iEP~wq 4;{o?g^;N:$BR6 4Mvsi-@R4 mUb V*XX! cyg$w.Q "@oWL 8*Byc jđ0蠦r,[LC 9VbX*x_yuoBL͐u_. DKfN1엓:+ۥ~`jn[Z p֖zg,tV@bW/Oټl6Ws[R?S֒7 _כ[֪7 _w]ŌSh N'^Bxk _[dC]zOլ\K=.: @MgdCf/ o\ycB95B24S CEL|gO'sקo>W=n#p̰ZN|ӪV:8z 1fk;ڇcp7#z8]Y / \{t\}}spķ=ʠoRVL 3N (B<|ݥuK>P.EMLhɦM .co;əmr"*0#̡=6Kր0i1;$P0!YݩjbiXJB5 IgAФa6{P g֢)҉-Ìq8RmcWyXg/u]6Q_Ê5H
Z2PU]Ǽ"GGFb CSOD%,p
6ޚwq̲R_gJSbj9)ed(w:/ak;6jAq11_ x zG~F<:ɮ>O&kNa4dht\?J&l O٠NRpwhpse)tp)af]
27n}mk]\S,+a2g^Az
)˙>E
G鿰L7)' PK !
ѐ ' theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э5
6?$Q
,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/ ]QAsم(#L[ PK- ! K [Content_Types].xmlPK- ! ֧ 6 1 _rels/.relsPK- ! ky theme/theme/themeManager.xmlPK- ! \ theme/theme/theme1.xmlPK- !
ѐ '
theme/theme/_rels/themeManager.xml.relsPK ]
! " # $ D S 9 , , , , , 8 , , ! " # $ D G S 1 W > t ! # $ 2& S) + (- / D1 & , 1 7 = B G J N S Y _ d i o q t R
z U & o ~ ! A r b d ` R h ! ~! ! " U" " " # t# # "$ F$ $ '% l% % & & Q( ( $) * ~* * + + , 6. . / 0 0 D1 ! " # $ % ' ( ) * + - . / 0 2 3 4 5 6 8 9 : ; < > ? @ A C D E F H I K L M O P Q R T U V W X Z [ \ ] ^ ` a b c e f g h j k l m n p r s u v w I U [ x { G W ; K
'
q
C S Z j g
w
3 C W g N Z ` t [ g m 3 C : J # 3 ] m ~ ; K . P \ b T d # 3 : J # ( 9 E K R ^ d x S FFFFFFG G G G G G G G G G G G G G G G G G G G G G G G G G G FFFFFFFFFFFFFG G G G G G G G G G G G G G G G G FG G G FG G G G FFFFFFFFFFFF 8 9 : @ 9 @ (
8
6 @ 8 " ?
9
6 @ 9 " ?
B
S ? 9 K S 8 A x = t 9 A x = t C h e c k 1 T e x t 1 0 T e x t 1 1 C h e c k 2 T e x t 1 2 T e x t 1 3 T e x t 6 T e x t 9 | O : T a L T 1
: }]E|& SQl$) 8Xx1 h ^`B* OJ QJ o( ph h ^`OJ QJ o( o h p p^p`OJ QJ o( h @ @ ^@ `OJ QJ o( h ^`OJ QJ o( o h ^`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h P P^P`OJ QJ o( r h^ `rOJ QJ o( ^`OJ QJ o( o p p^p`OJ QJ o( @ @ ^@ `OJ QJ o( ^`OJ QJ o( o ^`OJ QJ o( ^`OJ QJ o( ^`OJ QJ o( o P P^P`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h p p^p`OJ QJ o( h @ @ ^@ `OJ QJ o( h ^`OJ QJ o( o h ^`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h P P^P`OJ QJ o( 7 7^7`o( ^`o( . ^ `o( . . 1 f f^f`o( 1 . 1 . 1 . 1 ^`o( 1 . 1 . 1 . 1 . 1 ^`o( ^`o( ^`o( ^`o( SQ }]E 8X 1
t n l @38 8 9 O G P _ m n { 9 : G Y | } 9 : ; M r s
h i
)
^
_
q
A B C U w x
E F Z l e
f
g
y
" 1 2 3 E U V W i ' F G b J K + : ; \ 1 2 3 E z { 8 9 : L t u ! " # 5 P Q ] o | } ~ + , ; M 0 # $ d e n } R S T f # 5 8 9 : L z { + J K f
T " 6 z " 6 z @ V V V V V h h ] ] S @
@ 8 @ @ @ & P @ * , . 0 U n k n o w n G T i m e s N e w R o m a n 5 S y m b o l 3 A r i a l ; ~ W i n g d i n g s ? 4 W i n g d i n g s 2 A A r i a l N a r r o w 7 V e r d a n a 7 p!4 C o u r i e r ? 4 C o u r i e r N e w
h ̆̆ F 4 d K#q ? Q 0 F u n c t i o n a l A s s e s s m e n t S u m m a r y R o b e r t D i R e n z o R o b e r t D i R e n z o
Oh +'0 D( 8 D
h t
' Functional Assessment Summary Robert Di Renzo Normal.dotm Robert Di Renzo 2 Microsoft Macintosh Word @ @ )e@ `@ ` G & PICT&| Z H H Z
Z H H fd Z Z B!B !! !{!# ! wswso{s kZ!M !wcZso{kZskZscs
o{sswswg9kZkZskZ { o{!g !"wNs^^JRRNsF1RNsRRNsVg9F1VRVNsJRZF1RJRNsRF1Bsswswc^cc^ o{![ !"wVsF1BZJRJRBF1ZB5ZVJRJRB=9JRB5VZ5JRV=o{sws{ o{!) ! wswswsw{ o{!/ !w^Rswssg9g9^s o{!; ! w^NsZ=F1Ns5F1JR5JRZsws{ o{!M ! wZRVJRccR^RJRkZVswswww{{{ o{!U ! ws g9swsscZg9ZkZZcsZc^Z^^V{w w o{!- !wkZo{s o{sws{ o{![ ! wg9R^RJRJRNsNsRJRRVNsJRZZJRVVJR^RNsNsJRkZssws{{ o{!M ! wkZo{o{so{o{kZkZso{kZkZo{skZo{kZswssZZ{ o{!S ! w^R^VV^VVNsVVR
VR^V^RcRVZo{sws{ o{!O !wc^^Z^cZVZ^g9^cZ^g9^Z^ kZsws{ o{![ !wkZg9g9cg9g9cg9kZg9g9kZg9kZcg9g9o{s wso{Zg9V^^Vc{ o{!S ! w^R^VRVNsZ^V ^VV^RVZVVF1VVg9sws{ o{!M !wso{o{kZg9g9kZckZo{g9o{kZkZo{g9kZ o{sws{ o{!q !wZNsRNsVNsZVRVRRNs^VNsRJR^VNscR kZsws{ so{kZZkZo{cg9o{cg9g9 o{!m !wkZg9cg9kZg9^ckZg9kZcg9cg9g9kZcg9co{sws{ wwo{so{so{o{{o{ss o{!S !wcg9Z^g9^Zg9^ZcZg9Z^Zg9^c^kZZ kZsws{ o{! ! {wwkZo{! !!E !g9RkZcg9kZso{Zc^sckZZkZg9kZ^Z^^Zg9kZkZ!C !
o{kZVcg9Vcg9co{wc ^g9cZRs^cZ^^ZZ! !{{! !{{ {!# ! o{ZZkZ^kZZ^Vo{!_ !wckZkZg9o{g9g9kZg9kZo{cg9o{ckZco{g9ccg9sg9 sg9cg9g9wg9cg9g9kZg9w! ! {ww{wws{{w{w{s{w{wsww{{w{{w{ww{sw{w{wsw{w{{w{w{w{{w{w{w! !{{o{kZsso{sskZo{o{wso{so{kZwkZo{kZswo{
so{wkZwo{kZso{skZo{{so{kZo{o{kZo{so{so{skZswo{wkZo{o{so{kZ! ! wg9ckZg9g9kZcg9o{g9 o{g9ccg9o{g9g9kZsckZo{ckZg9kZco{cg9o{o{kZkZc^kZg9kZccg9^o{g9o{^g9g9co{g9kZo{kZg9c^s! !skZo{so{so{#sswkZso{so{wswsskZswo{kZwo{wkZsso{o{wsso{o{wo{so{wso{o{skZso{o{s{!w !{sswo{ssws{wswwswswwsw{wws{w{wwsww{sswwsw{ww{w sw {!; !w{skZcco{o{g9o{ckZkZg9g9o{g9g9o{o{cg9! !"{{{{{{{{w{{{{{{{{{ww{{ {{{{{{ {{{{! !Ksc^c^cckZccso{g9skZo{kZkZo{kZkZo{kZsg9kZkZskZkZo{o{g9g9kZskZkZo{o{kZkZg9kZkZo{kZo{kZo{o{kZkZsg9kZkZo{kZkZo{g9o{o{kZkZskZo{kZcsskZkZ{!l !o{g9wg9kZkZg9^o{kZkZccg9g9cg9o{g9^g9cg9g9o{g9ccg9kZg9kZcg9g9kZkZcg9g9cco{cg9! ! skZ w!) ! g9sg9^RRZkZcs kZ!A !g9g9kZkZg9sg9o{g9g9ckZcco{o{kZg9kZg9o{s kZ!C !g9VRRVVo{c^o{JRJR^^VNsR^ZNsco{ kZ!i !g9kZkZckZg9kZg9kZs cskZZo{scg9g9kZg9kZ^kZkZg9ckZg9 kZg9kZg9kZg9g9o{s kZ! !o{{wo{kZg9kZo{s*co{g9Vo{o{^^VcVZVZ^VVZVZVZ^R^^ZRVZVZ^VZVZVVZVVg9o{ kZ!K ! o{o{wg9o{g9g9kZskZkZo{kZg9sso{o{kZo{kZo{ o{!K ! o{ co{kZ^o{o{^g9ccg9^g9 ^g9g9c^cg9cckZo{ kZ!L ! o{o{sVo{g9c^ZZckZcZ^g9kZ^kZcc^ o{!/ ! co{ ^o{^o{o{kZo{o{kZo{ kZ! !o{g9sg9^^cg90o{sVo{^Vg9^kZ^kZ^cckZ^ckZ^scc^kZcZZcZcZo{kZc^^kZ^c^cg9kZZcc o{!O ! o{co{o{kZo{o{^o{kZkZo{ kZo{kZo{o{kZo{ kZo{ kZo{ kZ!u ! o{ o{sZo{^Vo{^ckZ^ZkZc^g9cc^ccg9kZc^g9o{c ^^kZcZg9g9^cZcwo{{Z!r ! o{ co{kZZo{o{^co{o{kZ o{kZo{o{kZo{ kZo{kZkZo{kZo{o{kZkZo{g9kZkZo{kZo{kZ g9o{kZo{c! ! o{ o{wg9o{o{cZ^*kZcZckZkZ^co{ccZkZ^c^VcZckZ^kZc^cg9o{g9Z^c^^g9g9^g9cg9^kZo{o{o{Z!3 ! o{ o{o{g9ckZg9g9kZwo{kZZ!+ ! co{ ^o{ ^g9 kZo{kZkZV![ !o{kZo{Z^^cg9o{sVo{g9^kZVg9g9^kZc^kZ^g9^^Zo{o{Z!a ! o{wswo{o{wo{so{ssco{kZg9o{o{^kZkZo{kZkZo{g9o{kZo{kZo{ kZo{kZg9R! ! o{skZkZso{kZskZswkZ+o{sZo{^Vo{^ckZ^ZkZc^g9cc^ccg9kZ^g9Zo{^cg9ckZc^cZcZg9^co{wc!e !o{g9^cZ^sco{kZ^o{o{^g9o{o{kZo{kZo{o{kZo{kZo{kZo{kZkZo{kZo{kZo{kZkZR!U ! o{o{wco{kZcZZ^^kZcZ^g9kZ^kZ^kZc^Zco{o{o{^!v ! cg9g9cg9ccg9g9cg9kZo{
^o{g9Zo{o{^cZg9g9cg9kZg9 cg9kZcg9kZg9kZg9ckZg9ckZg9o{kZkZV! !o{o{wcg9o{o{cg9 s0kZ{sc{{kZg9cg9^o{cg9cg9g9^cg9Zcc^cc^g9cg9Zo{^c^^g9g9o{c^kZcckZcc^kZ{kZkZV!= ! o{cskZZsscc^kZg9g9kZg9g9o{skZs^!= ! o{co{g9Vo{o{^ZZcVZ^ZRg9o{kZkZV!w ! o{ o{wg9o{o{kZkZg9g9kZwo{g9kZo{skZso{skZkZskZo{kZg9kZwo{kZsso{kZskZg9kZso{s^!y ! co{*^o{kZ^o{o{^cc^cc^cc^cg9g9cc^kZc^cc^c^cg9cg9cZg9g9cc^Zg9c g9o{kZs^!w !/o{g9scZccZZcZcco{sVo{^Vg9^kZ^kZckZ^kZ^Zg9c^kZ^ccg9^kZZ^so{kZR!G ! o{ { co{ ^o{kZkZo{ g9o{kZg9o{ kZo{kZo{^!i ! o{o{sZo{^Zo{g9g9o{cco{kZo{g9cg9co{cg9cco{o{cg9g9co{^ckZo{o{V!T ! o{co{kZco{o{^kZ g9kZg9g9kZckZg9kZg9kZ g9kZ g9o{kZo{Z!e ! o{#o{sZo{g9c^ZZ^kZcZ^g9kZZckZ^o{cZg9^ZkZ^^cg9c^o{kZV! !cg9kZkZo{g9o{g9g9o{^o{kZZo{o{^g9ckZg9o{kZo{kZo{kZo{kZg9o{kZo{kZo{kZkZo{kZo{kZo{kZo{ckZo{ kZo{kZkZg9! ! o{kZs^c^^g9ccZ{
o{wg9o{g9cg9^kZ^g9c Zg9cZcg9kZ^cZkZ^s^c^^o{^ZcZkZ^ckZkZc^cZs o{!y ! o{co{g9Zo{o{^c^kZg9g9kZg9kZg9g9kZg9kZg9kZg9kZkZckZ
ckZg9kZkZg9kZg9kZkZg9kZg9cg9o{ kZ! ! o{$co{g9Vo{o{^VR^NsRZRNsZRNsRF1ZNsVRVNsZRNsRVR^NsRZNsRZRRNsRNsNsVRVNsRNsVNsRo{ kZ!D ! o{o{wg9o{so{wso{o{so{kZws o{!K ! co{^o{g9Zo{o{^c^Z c^Z^ccZ^Zg9^^Vo{ kZ! !o{swkZo{kZ{'o{wg9o{g9co{kZo{kZso{o{kZo{so{skZo{o{kZskZo{o{so{g9o{wo{so{skZskZo{kZs o{!v !o{{{wso{ssco{kZZo{o{^c^g9c^c^^cZ^ccg9^^c^g9cc^^c ^co{ kZ!; ! o{o{wco{g9^skZkZsg9g9{ o{!7 ! o{co{kZ^o{o{^g9 cg9^kZo{ kZ!S ! o{o{sVo{g9kZkZg9g9kZwo{g9kZkZwo{scsg9kZco{kZ o{!U ! o{ o{sRo{cZRNsNsRcZNsRccR^V^NsF1^NsV{ o{!R ! ckZ g9kZo{ ^o{kZ^o{o{^kZg9kZo{kZg9o{kZkZo{kZo{kZkZo{ kZ!k ! o{g9o{^^Zc^^cZs o{wco{cZg9^kZ^ckZc^^g9o{^kZccg9g9kZZc o{!k ! o{co{kZ^o{o{^g9g9o{kZo{kZkZo{kZkZo{kZo{o{kZo{kZo{o{g9o{kZkZo{o{g9kZo{ kZ! ! o{o{wg9o{c^o{^ckZcZkZcckZg9^ccg9cZkZo{^c^sco{^kZckZcckZg9kZZc^kZo{c^wkZckZ o{!{ ! o{ o{,o{kZckZcg9o{o{g9o{co{g9g9skZco{g9kZkZskZg9kZg9kZo{ckZg9kZccskZg9o{co{o{kZg9g9kZ o{!e ! o{ co{ ^g9 cg9^kZg9g9cg9ckZg9cc^g9kZc^g9g9cg9cg9^g9^kZo{ kZ! ! o{3o{sZo{kZg9g9^cco{g9^ckZo{c^skZo{kZ^c^g9co{kZ^g9g9o{^g9o{kZ^o{cg9g9o{g9g9kZg9cg9ckZco{ o{! ! o{
o{{o{w{ssw{s{{{{{{{{w{{w{{{{{w{{ o{!5 ! co{ ^o{ ^RRZNsVRRNsZo{ kZ!L !o{o{so{o{g9wso{o{wg9o{kZwo{o{wsso{w o{!O !o{w{o{swo{sskZco{g9Zo{o{^^c^Zg9Z^Zg9o{ kZ!G !o{g9^cZco{wg9o{g9kZkZso{kZo{kZkZ{ o{!; ! o{ co{kZZo{o{^c^^c^c^kZo{ kZ!S ! o{o{sZo{g9c^^g9kZcc^g9{g9o{^^ckZ^ccs o{!F !ckZo{kZo{g9o{kZo{g9kZo{kZkZckZo{kZ ckZo{ kZ!A !o{ZZRZVRZ^VR^wRVZRVg9VV^ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! ! o{ o{! !o{ s! !!K ! wVNsZVVcR^RVZRVVRcVZVZ^RZVZcF1c!K !o{ccg9cg9cg9g9cg9 ^g9cg9cg9cg9cg9cg9g9cw!Q !w^JRVNsJRRVNsNsJRNsRo{sZRVZVRcZV^RVkZ^c{! ! ws {!1 !wZRZs^VRZVR^g9s {!# ! o{c^^c^c w!> !wkZkZskZkZo{g9kZo{s o{kZo{o{kZo{s {!O !o{RF1Zc VJRVJRRNsJRF1^c^c^c^RJRJRRNsJRRc w! !! !! !! !! !!
՜. +,D ՜. +, H x
* ' Department of Human Services Functional Assessment Summary Title P : B _PID_LINKBASE ' A
! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~ R o o t E n t r y F -IA` D a t a
+] 1 T a b l e H W o r d D o c u m e n t S u m m a r y I n f o r m a t i o n ( t( D o c u m e n t S u m m a r y I n f o r m a t i o n 8 C o m p O b j ` O b j e c t P o o l HA`HA` F Microsoft Word 97-2004 Document NB6W Word.Document.8