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Dodd Forms

Dodd Forms

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Providers0 Licensed or Certified Provider Staff or Family living at the Individual s home responsible for the individual s care. LE Name Badge Number Jurisdiction and contact information required for Law Enforcement Enforcement CPSA Name and contact information required for Children Services County Board Administrator Required for ICF Support Broker If applicable Name/Title Date/Time Additional Information/or Administrative Follow-Up A. Further Medical Follow-up B. Administrative Action...
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