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2 only in response to external stimuli less than once a 3 only in response to external stimuli at least once a 4 without cause less than once a day 5 without cause once a. _ ____ _ _ ____ _ _ ____ _ _ ____ _ _____ _ TOTAL Federal Outlays1965911,2531,789in Defense Discretionary8154242in Nondefense Discretionary8172437 _ ____ _ _ ____ _ _ ____ _ _ ____ _ _____ _ TOTAL R&D ____/____/____ NOTE: This form cannot be used to request ECT or psychological testing . Type of Service Requested:  Mental Health  Substance Abuse Patient Name: _____ Page 1 of 4 7/2012 Property Address _____________________________________ Buyer’s Initials____/____ NEBRASKA REAL ESTATE COMMIS S ION SELLER PROPERTY CONDITION DISCLOSURE STATEMENT Resident Dry & Slept ____ Dry & Woke ____ Wet during night ___ Dry & Slept ____ Dry & Woke ____ Wet during night ___ Dry & Slept ____ Dry & Woke ____ Wet during night ___ Dry & Slept ____ Dry & Woke ____ W unable _______ unbuckle ____ __ _______ _________ pretest __ ________ __ unlimited __ ______ ____ _______ unclear ________ precook ___ ________ unsure ____ _______ ______________________ ________ prep HECKLISTREASExecutiveOfficer,IpswichCityCouncil UseOnly No:______________ Rcd:____/____/____Officer:__________________________________________ madeapplicationthedevelopmentapplicationreducesinstancesw HECKLIST UseOnly No:______________ Rcd:____/____/____Officer: madeapplicationthedevelopmentapplicationreducesinstanceswherebyCouncilneedsrequestinformationapplication.Checklisthasbeendesignedassistyou Date:____ English 11 Period: ____ VOCABUALRY - LEVEL F - UNIT 2 Pre - Test CCSS.ELA - Literacy.RI.11 - 12.4 Determine the meaning of words and phrases as they are used in a text, including figurativ 1 Nissen Fundoplication Name:__________________________ ____ __ Date:___________________________ ____ __ Dietitian:__________________________ ____ Telephone:_______________________ ____ __ Questions? _____Se"'uaZ. .____-Diyestive. _____Spinal. ____Oereb•.al. } ___Hyste"ia. ___HYPOchondria. ________Hay-Fever. _____AsthenOPia. .;___Sleeplessness. 1: .. _____ Chorea. ._____Nea•.-si(Jhtednes Copyright 2007 (909) 399-3104 www.pbguitarstudio.com POS II POS I POS III PENTATONIC LADDERS ____/____/____ Copyright 2007 Pebber Brown (909) 399-3104 www.pbguitarstudio.com PENTATONIC 1 /17 To day’s Date: ____/____/____ Group Name : ______________________________________ ________ _ _________________________ __________________________ Address: _______________________________ Child’s Name__________________________________________________. . LAST FIRST MI. Birthdate: _____/_____/____ Age:______ □ Male □ Female. Item. 1.How willing are you to make changes in your eating habits in order to be healthier?*. 1. Very Willing. 2. 3. 4. 5. Not at all Willing. 2. Are you interested in participating in a dietary and lung health study?.