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Impairment Form

Version 4

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Title:Impairment Form
Summary:
Description:
Keywords:
Handle: Document-72877
Owner: Welch, Denise (User-5470, dwelch0001:System Office)
Create Date:Wednesday, February 27, 2002 01:42:07 PM EST
Modified Date:Wednesday, August 25, 2004 03:02:04 PM EDT
Modified By: Welch, Denise (User-5470, dwelch0001:System Office)
Expiration Date:
Locked By:
Abstract:
  • MEDICAID NURSE AIDE APPROVAL FOR ALTERNATE FORM OF TEST (To be requested by the Nurse Aide Test Candidate Only) Please contact your coordinator at least two weeks in advance to review your impairment needs and verify test appointment ______________________________ _______________________ Test Candidate s Name (Please Print) Social Security Number Pursuant to 42 CFR 483.154, I am requesting to take an alternate form of the test for Medicaid Nurse Aide.
  • I am requesting the alternate form because of one of the following criteria (please check one): ( ) has a reading impairment ( ) has a sight impairment ( ) has a hearing impairment ( ) will bring translating dictionary Your name may be ...
Add Versions:Allowed
Author:Denise Welch
Content Type: Microsoft Office Word (.doc, .dot, .docx) - application/msword
File name:ImpairmentForm.doc
Is Placeholder:
Max Versions:1
Size:26624
Ready for Declare:No
Appears In: _Nurse Aide Program
Preferred Version: Impairment Form