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DEPARIMEITT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEOICARE & MEOTCAIO SERVICES

5URVEYOR NOTES WORKSHEET


Facility Name:

Surveyor Name:
Surveyor

Number:-__-

Observation Dates: tr'rom


TAG/CONCERNS

DOCUMENTAROH

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DIPARTMENT OF HEAI-TII AI{D HUMAN SERVICES


MEDICAID
CENTERS FOfi MEDIgARE

SERVICES

Surveyor Number:.

DOCUMEilTANON

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