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* 1. Contact Information

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* 2. Facility Type

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* 3. Name of Facility

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* 4. Arrival Date

Date / Time

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* 5. Arrival Time

Date / Time

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* 6. Departure Time

Date / Time

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* 7. Travel Time (in minutes)

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* 8. Record Keeping Time (in minutes)

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* 9. Number of Residents Visited

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* 10. Weekly Narrative

T