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Get WI F-62373 2009-2024

And 88.05(4)(d)2a and b, Wisconsin Administrative Code, within 3 days of admission and must be retained in the resident’s record. Failure to complete this form could result in Department sanctions. Name – Facility Date Form Completed Address Name – Resident Apartment or Room Number Name – Evaluators The ability of residents to successfully use a means of egress depends on how they will perform in an actual emergency. This sample checklist has been adapted from the Fire Safety Evalu.

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