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S. Any section not completed does not invalidate the form and implies full treatment for that section. A Last Name First Name/Middle Initial Date of Birth: (mm/dd/yyyy) Gender: (circle) Last 4 SSN: M F CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse AND is not breathing. Attempt Resuscitation/CPR DO NOT Attempt Resuscitation/CPR (DNR/No CPR) Check one (NOTE: If Attempt Resuscitation/CPR is checked in Section A, Advanced Interventions must also be checked in Section B.

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