| Document Date: 2010-12-28 12:00:28
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City Facility / Resident / / Company RAI / / Facility Facility ID / The facility / Facility Name / / IndustryTerm activities involving food / transportation / therapy services / offered transportation assistance / social services / resident access transportation / or arrange services / low-energy programs / role social services / care and services / timely transportation / needed counseling services / supplies/equipment / / MedicalCondition illness / / Organization resident/responsible party / / Person Interview Interview / / Position physician / Representative / Activities Director / qualified activities director / Surveyor / player / resident/representative / Nurse / /
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Facility Name: Facility ID: Date: