Health & Pregnancy History Assurance of Confidentiality: The information on this form is being requested on a voluntary basis. The information that you provide will help us to deliver or direct services most appropriate for your family’s needs. Some of the information may be used to help plan national program initiatives. If you prefer not to provide some of the information, it will not affect the services we try to deliver. However, some information is required for eligibility determination. All information will be held in strict confidence.
Date: __________________ Enrollee’s Name: _______________________________________________________ Date or Birth: __________________________ SSN: ___________________________ Address: __________________________ Telephone: _________________________ __________________________ Marital Status: _____ Single _____ Married _____ Separated ______ Divorced
Is the applicant a teen parent: Yes or No Current Pregnancy:
Are you currently receiving Prenatal Care: Yes or No If no, please indicate why: ________________________________________________________________________ ________________________________________________________________________ If you marked yes, please fill out the following information: Month of 1st Prenatal Care visit: _____________ Expected delivery date: ____________ Which trimester is this pregnancy? _______ First _______ Second _______ Third Have you received an ultrasound? Yes or No
If yes, date of ultrasound: _____________
Date of next scheduled prenatal visit: _________________________________________
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
Time between this and last pregnancy: ____ none ____ less than 18 months ____ more than 18 months # of full term births: _____
____Norplant ____ Diaphragm/Cervical Cap
____ Tubal Ligation ____Oral Contraceptive Pill
____ Other (specify) ____________________________________________________ Service Providers
Where do you receive your prenatal care from? Prenatal Care Provider: ___________________________________________________ Address: _______________________________________________________________ Telephone number: ______________________________________________________ Date of last pap smear: _______________ None in past 2 years ____Don’t remember Pap results: ____ Normal
Do you receive services from any of the following sources: ____ Native Women’s Clinic _____WIC _____Indian Health Services _____ Other Are there any services that you presently need: ________________________________ What transportation method do you use for appointments: ________________________ Do you need assistance for transportation to appointments: Yes or No Do you have any chronic or acute medical conditions:
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
List any known allergies you have: __________________________________________ List any medications that you are presently taking: ______________________________ List any medical conditions you are presently experiencing: _______________________ ________________________________________________________________________ ________________________________________________________________________ Assistive Devices Used:
_______ None _______ Glasses/Contact Lenses _______ Hearing Aid _______ Braces _____ Crutches/Walker/Cane _____ Wheelchair _____ Other (specify) ____________ _______________________________________________________________________ Risk Assessment Are you experiencing any complications with this pregnancy:
Have you experienced complications with any other pregnancies? Yes or No If yes, please specify: Complication
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Are there any of the following risk factors present in your current living situation? ____ None _____ toddlers in home _____ lack of social support _____ homelessness ____ Language barrier ____impaired cognitive ability _____domestic violence ____ drug/alcohol use/abuse _____Other (specify) ______________________________
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
Are you attending any support or educational groups:
Please specify if yes: ______________________________________________________ Drug Use History
Have you ever attended an alcohol/drug treatment program:
If yes, dates and location: _________________________________________________ Did you successfully complete:
Do you feel you presently have a need for alcohol/drug services: Yes or No Please check off which substances you presently use: Substances used
Would you like assistance with seeking services for alcohol/drug use: Yes or No Disabilities Do you have any disabilities for which you are presently receiving services? Yes or No Visual disabilities: Yes or No
Hearing impairment including deafness: Yes or No
Orthopedic impairment: Yes or No Speech or language impairment: Yes or No Health impairment: Yes or No
Emotional/Behavioral Disorder: Yes or No Traumatic Brain Injury: Yes or No Autism: Yes or No
Other impairments: _______________________________________________________
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
Primary Occupational Status (mark one) _____ Paying Job
__ Other: (specify) ________________________________________________
Highest level of application completed: _______________________________________ Are you willing to pursue educational opportunities:
If yes, what assistance would you need in order to pursue these goals (specify): _______________________________________________________________________ _______________________________________________________________________ 1. I declare under penalty of perjury that the information provided is true and correct to the best of my
2. I understand that I will receive a notice of approval or disapproval of my eligibility application. 3. I understand that this certification is not complete until all documentation is submitted and this form
has been reviewed, signed, dated by an agency representative and signed and dated by me.
4. I understand there is additional paperwork for me to fill out if my child is approved for Early Head
_______________________________________________ _________________________ Signature Date
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
11th TRAIL Congress November 2010 BENCHMARK FRAMEWORK FOR SENSITIVITY ANALYSIS OF DYNAMIC OD DEMAND ESTIMATION METHODS Tamara Djukic MSc, Dr. ir. Hans van Lint, Prof. dr. ir. Serge Hoogendoorn, Prof. dr. Henk van Zuylen Faculty of Civil Engineering and Geosciences, Department of Transport and Planning, Delft University of Technology, the Netherlands ABSTRACT The ind
Parte I: Lista dos objetos proibidos e aceitos sob condição para a importação (ou em trânsito) Seção I – Animais vivos e produtos animais Capítulo 1 Animais Vivos Posição Código SH Objetos proibidos Objetos aceitos sob condição Abelhas, bicho da seda e sanguessugas acompanhados de certificados zoossanitário. Ver Parte II, §§ 2 e 2.2.
Health & Pregnancy History 
Time between this and last pregnancy: ____ none ____ less than 18 months ____ more than 18 months # of full term births: _____
____Norplant ____ Diaphragm/Cervical Cap
____ Tubal Ligation ____Oral Contraceptive Pill
Are you attending any support or educational groups:
Primary Occupational Status (mark one) _____ Paying Job
__ Other: (specify) ________________________________________________
Highest level of application completed: _______________________________________ Are you willing to pursue educational opportunities:
If yes, what assistance would you need in order to pursue these goals (specify): _______________________________________________________________________ _______________________________________________________________________ 1. I declare under penalty of perjury that the information provided is true and correct to the best of my
2. I understand that I will receive a notice of approval or disapproval of my eligibility application. 3. I understand that this certification is not complete until all documentation is submitted and this form
has been reviewed, signed, dated by an agency representative and signed and dated by me.
4. I understand there is additional paperwork for me to fill out if my child is approved for Early Head
_______________________________________________ _________________________ Signature Date
P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)