╨╧рб▒с>■  )+■   (                                                                                                                                                                                                                                                                                                                                                                                                                                                ье┴[ Ё┐Bbjbjтт АjАj-      lPPPdVVVV b4dв╢ввввв   !######$X x╞GP  Ї   G│ вв{\│ │ │  8вPв!│  !│ Т│ E8PEвЦ ░╝╗%? ─dЄV' EE▄r0вE>= v>E│ dd┘ This Client is considered Inactive (Moved or Gone Elsewhere): 2 or less Acute Visits Have Moved Out of Area Seeing Other Provider  __________________________________________ New Primary Care Provider _________________________________ Staff Signature  _________________________________ Date (Mo/Day/Year) This Client has refused vaccination for the following reason(s): Religious* Moral* Philosophical* Medical**  __________________________________________ Primary Care Provider Signature _________________________________ Client/Guardian Signature _________________________________ Date (Mo/Day/Year) *Written exemption by parent/guardian must be on file. **Written explanation by provider must be documented in file. S/program/immunize/casa/moge face page.doc G_vНОСФ┐█¤0Щем╟╔═╤№@[|?B¤¤ЄЁЁЁ¤¤ЄЁЁЁЄь:БCJ >*jUmHnHuCJEFG^_vwНОТ¤¤¤¤¤¤¤ўё╛0ёё╕ёёёё$If2$$IfЦl4╓Ф f!╥!Ў6╓ ╓ ╓ ╓ 4╓ laЎ$If$IfA¤¤ТУФ┐┘┌█¤1M╗╡╡╡В╨╡╡╡╡╡╡2$$IfЦl4╓Ф f!╥!Ў6╓ ╓ ╓ ╓ 4╓ laЎ$IfD$$IfЦl╓0Ф lf!╪·Ў6╓  ╓  ╓  ╓  4╓ laЎ MNOPQRSTUVЧШЩд╣│А~~~~~~x│А╪│$If2$$IfЦl4╓Ф f!╥!Ў6╓ ╓ ╓ ╓ 4╓ laЎ$IfE$$IfЦl4╓0Ф ,f!Ш:Ў6╓  ╓  ╓  ╓  4╓ laЎ демн╜╛╚╔╬╧╨╤№∙є∙∙∙∙∙∙п8∙∙∙∙|Ї2$$IfЦl4╓Ф f!╥!Ў6╓ ╓ ╓ ╓ 4╓ laЎD$$IfЦl╓0Ф lf!╪·Ў6╓  ╓  ╓  ╓  4╓ laЎ$If$If@Z[}ЩЪЫЬ╙?∙∙∙∙∙∙│р∙∙∙∙А~~2$$IfЦl4╓Ф f!╥!Ў6╓ ╓ ╓ ╓ 4╓ laЎE$$IfЦl4╓0Ф ,f!Ш:Ў6╓  ╓  ╓  ╓  4╓ laЎ$If?@AB¤¤¤░╨/ ░р=!░"░#Ра$Ра%░ i0@ё 0 Normal_HmH sH tH 0@0 Heading 1$@&CJ 0@0 Heading 2$@&CJ<A@Є б< Default Paragraph Font,B    ,/  B    EFG^_vwНОТУФ┐┘┌█¤1MNOPQRSTUVЧШЩдемн╜╛╚╔╬╧╨╤№@Z[}ЩЪЫЬ?CШ0ААШ0ААШ0ААШ0ААШ0ААШ0ААШ0ААй0ААй0ААЩ0ААй0ААй0ААй0ААй0ААл0ААй0ААй0ААЩ0ААй0ААй0ААл0ААЩ0ААй0ААй0ААй0ААй0ААй0ААй0ААЩ0ААй@0ААЩ@0ААШ0ААШ0ААШ0ААШ0ААШ0ААШ0ААй0ААй0ААЩ0ААй0ААй0ААл0ААй0ААл0ААй0ААл0ААй0ААй0ААЩ0ААй@0ААй0ААй0ААл0ААЩ@0ААй@0ААй@0ААй0ААй@0ААй@0ААй@0ААЩ@0ААй0ААл0ААл0ААЩ0ААЪААШ0ААЪААBТMд?B AЁ8Ё@ё   АААўЁ2Ё Ё╨Ё( Ё ЁЁ( Ё ЁЁЁ( Ё ЁЁЁ( Ё  ЁЁЁ( Ё  ЁЁЁ( Ё  ЁЁЁ( Ё ЁЁЁ( Ё ЁЁЁHв Ё # Ё А ЁЁ ЁЁB ЁS Ё┐╦  ?ЁОПР╔╩╦╠B▐   ТТFt ▐   оТbtу   GЧ√t ▐   ТТFt▐   оТbt▐   ╩Т~t у   GЧ√t5■  3ЫT@C@CCE}Г┐┐╪╪PUVC   Shawn BoxMC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of Document1.asd Shawn Box?S:\PROGRAM\IMMUNIZE\CASA\This Client is considered Inactive.doc Shawn Box?S:\PROGRAM\IMMUNIZE\CASA\This Client is considered Inactive.doc Karen Damren,S:\PROGRAM\IMMUNIZE\CASA\MOGE Face Sheet.doc Karen Casey,S:\PROGRAM\IMMUNIZE\CASA\MOGE Face Sheet.doc Shawn Box,S:\PROGRAM\IMMUNIZE\CASA\MOGE Face Sheet.doc Karen DamrenIS:\PROGRAM\IMMUNIZE\CASA\2002 CASA Training Materials\MOGE Face Sheet.doc Shawn BoxNS:\PROGRAM\Immunize\FORMS\PROVIDER\providers_forms_04\MOGE Face Sheet 2004.docFGОТУ┘┌MNOPVШЩ╔╬╧ZЩЪCЮ"╛ЮЮЦЮ"╛ЮЮЦ @А@∙tB`@  Unknown            GРЗz А Times New Roman5РАSymbol3&Р Зz А Arial"ёИЁ╨hьКГfьКГfbbFqЙЙ#Ёе└┤┤Аr0d2ГЁ▀  <This Client is considered Inactive (Moved or Gone Elsewhere) Shawn Box Shawn Box■ рЕЯЄ∙OhлС+'│┘0└ШашЇ 4 HT p | И Фаи░╕ф=This Client is considered Inactive (Moved or Gone Elsewhere)(his Shawn Boxt hawhaw Normal.dot  Shawn Box 2awMicrosoft Word 9.0i@@4r▒╟│┴@И- ? ─@И- ? ─qЙ■ ╒═╒Ь.УЧ+,∙о08 hpРШаи ░╕└╚ ╨ фImmunization Programc2 =This Client is considered Inactive (Moved or Gone Elsewhere) Title ■   ■   ■   !"#$%&'■   ¤   *■   ■   ■                                                                                                                                                                                                                                                                                                                                               Root Entry         └Fа╛%? ─,А1Table             >WordDocument        SummaryInformation(    DocumentSummaryInformation8             CompObj    jObjectPool            а╛%? ─а╛%? ─            ■                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ■       └FMicrosoft Word Document MSWordDocWord.Document.8Ї9▓q