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  • All fields: 2012-10-01)
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    • Petro Pros Profile Form

    • Petro Profile 2012-2013 Name Cell Phone _ Company _ Company Address, City, State, Zip Title _ Work Phone E-mail _ size _ Background Information _ Please list your preferences below. This will help us pair you with presentations that meet your...
    • 2012-09-06
    • Safety Standards Division Installer Application

    • 3017 N Stiles, Ste 100., OKLAHOMA CITY, OKLAHOMA 73105 PHONE: (405)521-6100 FAX (405) 521-6025 Revised 1/12/2011 Toll Free Number (888) 269-5353 Page 1 of 2 Oklahoma Department of Labor Mark Costello COMMISSIONER INSTALLER...
    • 2012-08-10
    • In-Home Supports Waiver -  Certificate of Competency

    • In-Home Supports Waiver 06IS037E (DDS-37) v.3 08/02/2012 Page 1 of 2 Certificate of Competency Name of habilitation training specialist (HTS)/direct support staff I want the above named person employed as HTS/direct support staff, and I certify the...
    • 2012-08-17
    • Incident Report

    • Incident Report Form 06MP046E (DDS-46) v.3 08/02/2012 Page 1 of 3 Client Information Staff completes this form to report critical and non-critical incidents involving a person receiving Developmental Disabilities Services Division (DDSD)...
    • 2012-08-17
    • OKDHS e-Release Submission Form

    • OKDHS e-Release Submission * Indicates Required Fields 16PR004E v.1 8-2-2012 Page 1 of 1 First name Last name City Email address Is this a media outlet? Yes No State County Complete this form to receive automatic notifications of OKDHS news...
    • 2012-08-17
    • Employee Identification ID Badge Request

    • Employee Identification (ID) Badge Request Form 23AM010E v.2 08/02/2012 Page 1 of 1 Badge Type Requested The division administrator must approve access to the PMO (Project Management Office) building. The division administrator must approve access...
    • 2012-08-17
    • Adult Day Services Monthly Report

    • Aging Services Division Adult Day Services Monthly Report Month of , 20 Name of center Total number of new Oklahoma Department of Human Services (OKDHS) participants approved: Name Case number Total number of OKDHS applications pending: Name Social...
    • 2012-08-22
    • Adult Day Services Referral/Application

    • Case number: County number: Adult Day Services Referral/Application A.Participant information: Name Date of birth Social Security number U.S. citizen Yes No If no, alien registration number Gender Male Female Race White American...
    • 2012-08-22
    • Annual Assessment

    • *02AG005E-001* OKLAHOMA'DEPARTMENT OF HUMAN SERVICES Aging Services Division Annual AssessmentArea Agency on Aging (AAA) Date completed 340:105-10-30. Designation of Area Agencies on Aging For an entity to be designated as an AAA, the agency's...
    • 2012-08-22
    • Voluntary Withdrawal of Title III Project

    • *02AG006E-001* OKLAHOMADEPARTMENT OF HUMAN SERVICES Voluntary Withdrawal of Title III Project When an Older Americans Act Title III funded project elects to voluntarily terminate a contract prior to the end of a grant year, procedures in paragraphs...
    • 2012-08-22
    • Cash Disbursements Journal

    • Page number [Enter page number] Organi-zation name: [Enter organization name] Month and year [Enter month and year] Previous total [Enter previous totals] - - [Enter amount of check] [Enter...
    • 2012-08-22
    • Cash Disbursements Journal

    • Page number: [Enter page number] Month and year of : [Enter month] Organi- zation name: [Enter organization name] Previous balance [Enter previous balance] Line number NSIP cash in lieu III-B...
    • 2012-08-22
    • Equipment Inventory

    • STATE OF OKLAHOMA DEPARTMENT OF HUMAN SERVICES EQUIPMENT INVENTORY Project name Office/site location Fiscal year ended Funding Source QTY Item description Manufacture serial number Inventory ID. number Acquisition Cost Date Vendor/supplier This is...
    • 2012-08-22
    • Request for Title XIX Nursing Assessment

    • *02AG001E-001* OKLAHOMADEPARTMENT OF HUMAN SERVICES Request for Title XIX Nursing Assessment Form 02AG001E is completed by the intermediate care facility (ICF) to notify OKDHS of a Medicaid client's admission into the ICF and request a nursing...
    • 2012-08-22
    • Older Americans Act Assessment, Part I

    • *02AG002E-001E* OKLAHOMADEPARTMENT OF HUMAN SERVICES Older Americans Act Assessment, Part I Initial date of contact Assessment *1Q2A1* Reassessment *1Q2A3* Date Source of referral to this office: Name Agency Agency case number Person providing...
    • 2012-08-22
    • Little Bits Workshop Registration Form

    • Little Bits Registration Form WorkshopDate: ~~~~~~~~~~~~ WorkshopInstructor~):~~~~~~~~~~~~~~~~~~~_ Name:~~~~~~~~~~~~~~~~~~~~~~~~~~_ Home Address:~~~~~~~~~~~~~~~~~~~~~~- City, State, Zip: ~~~~~~~~~~~~~~~~~~~~~~_ Phone:~---------~ E-mail:...
    • 2012-09-06
    • OERB Book Order Form

    • OERB Book Order Form THE ROAD TO PETROVILLE Join Petro Pete, Pappy Pete and RePete in The Road to Petroville. The first in the three-book series,Petro Pete learns about life in the early-day oil fields of Petroville, Okla. from Pappy Pete. Copies...
    • 2012-09-06
    • In-Kind Travel Expense Voucher

    • *02AG014E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES In-Kind Travel Expense Voucher Voucher number: for the month of , 20Traveler Purpose of travel Date From To Miles driven Total I certify that the above information is true and correct to the best...
    • 2012-08-22
    • Organization Financial Report

    • Organization Financial Report Adm. = Administrative Promo = Promotion Serv. = Services NSIP = YTD = Year to date A. Organization information AAA name Project name Address City Reported period Grant period Beginning Ending I certify that the...
    • 2012-08-22
    • Nutrition Project Attendance Form

    • *02AG016E-001* OKLAHOMADEPARTMENT OF HUMAN SERVICES Nutrition Project Attendance Form Date 20 Project name Site name: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35....
    • 2012-08-22
    • Project Menu Plan - Nutrition Program for the Elderly

    • *02AG018E-001* OKLAHOMADEPARTMENT OF HUMAN SERVICES Project Menu Plan - Nutrition Program for the Elderly Project director Project titleDate Meals Date Date Date Date Date Month/day/year Meat or alternate 3 oz. cooked, edible portion Vegetables and...
    • 2012-08-22
    • Records Check Documentation Form

    • Records Check Documentation Form Form 04AF007E (DCFS-109) v.3 08/09/2012 Page 1 of 7 Applicant Information Date of birth Social Security number First name Middle name Last name List other names used including maiden name, when...
    • 2012-08-24
    • Bridge Resource Parent Health History

    • Bridge Resource Parent Health History Form 04AF017E v.3 08/09/2012 Page 1 of 3 This form is used to obtain complete and accurate information regarding the prospective or current Bridge resource parent’s health history and is completed by the: (1)...
    • 2012-08-24
    • Telephone Interview Notice

    • Telephone Interview Notice Form 08AD093E v.1 08/09/2012 Page 1 of 2 Notice Information Date Case name Case # County # Supervisor # Worker # Before you receive or continue to receive benefits, you must be interviewed by telephone. Your interview is...
    • 2012-08-24
    • Renew My Benefits

    • Renew My Benefits Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 1 of 11 Case Information Case name Social Security number Your worker uses the information you report on this form to see if your household can still get help with food, SoonerCare...
    • 2012-08-24
    • Individual Attendance Record

    • STATE OF OKLAHOMA DEPARTMENT OF HUMAN SERVICES Project Site From 20 to 20 INDIVIDUAL ATTENDANCE RECORD Surname First Name Telephone Date of birth Address Race Sex DAY...
    • 2012-08-22
    • OERB Press Release Information Form

    • Press Release Information Form In order to inform your local newspaper about your efforts, please take the time to complete the following information to be used in a press release. Name: _ School: _ City: Local Newspaper: Grade(s) you teach:...
    • 2012-09-06
    • PetroTech Application

    • o Accept o Decline ID# _ Office Use Onlv •APetroTech APPLICATION Please print and fill in completely. *Incomplete applications will not be processed. PERSONAL INFORMATION: (Please list your legal name) Last Name _ First Name _ MI __ Birth Date...
    • 2012-09-06
    • OERB Workshop Evaluation Survey

    • OERB Workshop Evaluation Please fill out the following evaluation and give it to the designated participant in your classroom. Your feedback can provide us with valuable information which will help us do a better job of providing training to meet...
    • 2012-09-06
    • Curriculum Supplies Reimbursement Form

    • CJERJ3" 2012-2013 Curriculum Supplies Reimbursement Form The OERB will reimburse you for your out of pocket expeuses associated with curriculum materials. Just follow these steps. Step 1: Teach the OERB curriculum this school year. Step 2: Save...
    • 2012-09-06


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