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Get OH HEA 7713 2015-2024

Y: County: Telephone: FAX: Type of Facility:  Nursing Home  Home State: Health Agency  ICF/MR Name of Home Administrator: Name of Person to Contact: Email (s):  Hospital  RCF  Hospice  Staffing ZIP:  ACF  Other (please describe)_________________________ License Number: Name of Director of Nursing: License Number: Agency Signature of Home Administrator: Signature of Director of Nursing: Section II (Nurse Aide Information) List all nurse aides used by th.

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