Form Dhr Cdc 1948 PDF Details

Form Dhr Cdc 1948 is a document that was created by the Centers for Disease Control and Prevention (CDC) in order to track all cases of diphtheria reported in the United States. The form contains detailed information about each case, including the patient's name, age, sex, date of diagnosis, and location of treatment. It also includes information about the type of diphtheria and whether or not the patient died from the disease. This form can be used to help researchers learn more about the epidemiology of diphtheria and how to better prevent it from spreading.

QuestionAnswer
Form NameForm Dhr Cdc 1948
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswhat help can i get to collect child support in alabama, dhr alabama child support forms, alabama dhr child support excel sheet, alabama dhr forms addendum dependency

Form Preview Example

F.ReferenceForm

DHR-CDC-1948

REFERENCEFORM

Date___________________

To: ________________________

(ReferenceContact)

Address: ___________________________________________________________________________

(Street) (City) (State) (ZipCode)

__________________________________ hasapplied to workina child carefacility(home or center)

(Nameofapplicant)

asa _________________________________________. He/she hasgiven yourname asa persontobe

(Position)

contacted for informationregardinghis/her character,suitabilityto work withchildren andpreviousor prospectivejobperformance. Pleaseanswer thefollowing questionsandprovide anyadditional commentsthat could be helpful.Yourresponse will be kept confidential.

1.How longhave youknown thisperson? ________________________________________________

2.What is/wasyourrelationship withthisperson?(friend,employer, pastor, neighbor, etc.)

__________________________________________________________________________________

3.

Inyouropinion,isthisperson:

 

 

 

Comments: _______________________________________

 

Dependable?

Yes

 

No

 

 

 

 

 

 

 

 

Honest?

Yes

 

No

 

 

 

 

 

 

 

 

Eventempered?

Yes

 

No

 

 

 

 

 

 

 

4.

Toyourknowledge, doesthisperson:

 

 

Comments: __________________________________

 

Usedrugs?

 

Yes

 

 

No

 

 

 

 

 

Drinkexcessively?

 

Yes

 

 

No

 

 

 

 

 

Useabusivelanguage?

Yes

 

 

No

 

 

 

 

5.If youare/werean employer of thisperson, describe the typeof work theperson does/did and the quality ofthe workhe/she performed. What wasthe reason forthe person leavingyour employment,if applicable?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

6.If youhave young children,would youleave your own child/children inthe care of thisperson?

Yes

No

If no, please explain.

__________________________________________________________________________________

__________________________________________________________________________________

88

EffectiveJanuary22, 2001

7.Toyourknowledge, doesthisperson have qualities, traits,or abilitiesthat make him/her particularly suitableto carefor children?

Yes

No

Pleaseexplain.

__________________________________________________________________________________

__________________________________________________________________________________

8. Do youknow of anyreason why thispersonmight not besuitable to careforchildren?

Yes

No

If yes,pleaseexplain.

__________________________________________________________________________________

__________________________________________________________________________________

9.If youhave any additionalcommentsabout thisperson you feel wouldbe useful whenconsidering his/her application for employmentin achild carefacility, pleasestatebelow.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

 

 

_________________________________________________________

 

 

 

Signature

 

Date

Telephone number

Pleasereturnthisformto:

 

 

 

 

 

 

 

Name of personrequesting information:

 

CharlotteRay

 

 

Nameof childcarefacility(home/center):

Trinity Child Development Center

Addressof facility:

 

 

 

 

 

 

 

Street:

 

1400 OxmoorRoad

 

 

City:

 

Homewood

 

 

 

 

State:

 

Alabama

 

ZipCode:

35209

 

Telephone Number:

(205) 879-1749

 

 

 

 

If youprefernottoprovide areferenceforthisperson, please sign hereand return thisformtothe addressabove.

_________________________________________________________

SignatureDate

89

EffectiveJanuary22, 2001

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2. Soon after this part is completed, proceed to type in the suitable information in these - Address has applied to work in a, Comments, Yes Yes Even tempered Yes, No No No, No No No, Yes, and If no please explain.

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3. In this specific step, look at To your knowledge does this, Yes, Please explain, Do you know of any reason why, Yes, If yes please explain, If you have any additional, Signature Telephone number, Date, and Please return this form to. Each one of these will have to be filled in with greatest awareness of detail.

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