ࡱ> GI456789:;<=>?@AH#` =_bjbjmm .RN  ####$d ` s22222FFF$kh| GA,FGG22-HHHG2 2HGHHF H22 @W#GRHnHC0sHOGOHHO HXF"GHG1GYFFFGFFFsGGGG` ` ` $` ` `  $  Screening Tool for Entry to Licensed Residential CentresPerson Completing this Tool: Position:Agency Name:Referral and Assessment Centre, Home Care Service of NSWContact:Phone no:email:Date of AssessmentDate Assessment Completed (if different)People Present at Screening:First NameSecond NameOrganisation &/or Relationship to person being screened12345Referral Source: Who Referred this person for LRC Screening?Agency Name:Relationship or PositionPhone no:email:Person being ScreenedFamily Name/Surname:First Given Name:Also Known As:Current AddressSuburb/TownPost CodeTelephone number where person usually residesTelephone number where person can be contacted:Date of BirthGenderCountry of BirthPreferred Language Spoken at Home:AboriginalYesNoTorres Strait IslanderYesNoEmergency Contact / Next of KinRelationship Phone no:email:Current AddressSuburb/TownPost CodeSection 1 - Threshold Questions1Does the person consent to be screened for entry into a Licensed Residential Centre? Yes No2Does person consent to the assessor accessing documents such as medical records and progress notes, and seeking further information from relevant parties such as doctors, nurses and social workers?Yes No3Does person consent to a copy of their Screening Tool assessment being held by ADHC? This will be stored in a secure place and available only to officers involved in working with Licensed Residential CentresYes NoIf "No" to questions 1, 2 or 3 Person is not eligible for entry to Licensed Residential Centre - go to Section 6b4Is the person prepared to consider living in a Licensed Residential Centre?Yes NoIf "No" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b5Is the person able to carry out all tasks of personal hygiene? (e.g. washing, dressing). If assistance is needed short term, for example if someone has a broken arm and requires assistance 3 days a week for 1 month only, Home Care may be able to provide support.YesNoIf "No" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b6Does the person need 24 hour support?Yes NoIf "Yes" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b7What is the risk of the person harming themselves?  High Risk Medium risk Low Risk No Foreseeable RiskIf Low Risk, is there a management plan in place (please describe)? (100 words as a guide)If High or Medium Risk then this person is not eligible for entry to a LRC. Go to Section 6b8What is the risk of the person harming others? High Risk Medium risk Low Risk No Foreseeable RiskIf Low Risk, is there a management plan in place (please describe)? (100 words as a guide)If High or Medium Risk then this person is not eligible for entry to a LRC. Go to Section 6bIf the Questions have been answered as follows:Questions 1 - 3YesQuestion 4 - 5YesQuestion 6NoQuestion 7Low Risk or No Foreseeable RiskQuestion 8Low Risk or No Foreseeable Riskthen proceed to Section 2Section 2 - Background InformationCurrent living arrangements of the person for the last 12 months (if known) Psychiatric Hospital (name)Length of Time in hospital: Other Hospital (name)Length of Time in hospital: Private Residence client owns/ purchasingLength of Time in residence: Private Residence family member or related person owns/ is purchasingLength of Time in residence: Private Residence Private RentalLength of Time in residence: Private Residence public rental or community housingLength of Time in residence: Private Residence Aboriginal and Torres Strait Islander Community or SettlementLength of Time in residence: Independent Living within a retirement village Length of Time in residence: Licensed Residential Centre, (name)Length of Time in residence: Unlicensed Boarding House / Rooming House/Private HotelName/AddressLength of Time in residence: Short term / emergency or transitional accommodation Length of Time in residence: Supported Community AccommodationName/AddressLength of Time in residence: Public Place / Shelter Length of Time in residence: Other, please indicate Why Is the Person not returning to their last place of residence or their usual place of residence?Section 2 - Background Information ContinuedIncomeMain Income Source Disability Support Pension Paid Employment Compensation Payment Not Known  Other Pension / Benefit (specify)Section 3 - Support ServicesDoes the person have a case manager?YesNoNot KnownIf Yes:NameAgency Name:Phone no:email:Does the person have a legal guardian?YesNoNot KnownIf Yes:NameAgency Name or Relationship:Phone no:email:Is the person able to manage his or her own money, bank account and bills?YesNoNot KnownIf NO does the person receive assistance from a significant other (eg next of kin with Power of Attorney), or does he/she have a Financial Manager? It is a requirement under the Youth and Community Services Regulation 2010 that in the event that a resident is unable to operate his or her bank account or manage his or her financial affairs, the resident must be given support in arranging for such assistance as is required to operate the account or manage the affairs (including support in making an application to the Guardianship Tribunal for a financial management order where necessary). A resident must not be assisted by the licensee, licensed manager or other member of staff of the licensed premises in operating his or her bank account or managing his or her financial affairs.YesNoNot KnownIf Yes:NameAgency Name or Relationship:Phone no:email:Section 3 - Support Services ContinuedDoes person have a general practitioner?YesNoNot KnownIf Yes:NameAddressPhone no:email:Has the person had a comprehensive health assessment in the last 2 years? YesNoNot KnownRecord any care and support services provided to the person in the last 6 months (if known)AgencyService TypeContact DetailsSection 4 - Health ProfileHealth Conditions Psychiatric Disability If known, please describe Diagnosis by (if known)Date if known Intellectual Disability If known, please describe Diagnosis by (if known)Date if known Sensory Disability If known, please describe Diagnosis by (if known)Date if known Physical Disability If known, please describe Diagnosis by (if known)Date if known Acquired Brain InjuryIf known, please describe Diagnosis by (if known)Date if known Alcohol Related Brain DamageIf known, please describe Diagnosis by (if known)Date if known Organic Brain DiseaseIf known, please describe Diagnosis by (if known)Date if known DementiaIf known, please describe Diagnosis by (if known)Date if known Other Diagnosed Disease or DisabilityIf known, please describe Diagnosis by (if known)Date if knownSection 4 - Health Profile ContinuedMedicationIs the person taking medication? YesNoIs the person willing to take medication when prescribed by a doctor?YesNoDoes the person have a Community Treatment Order in place? YesNoIf YES, Agency administering medicationNameAddressPhone no:email:Review Date for Community Treatment OrderCan the person self medicate? YesNoMedication NameDosagePrescribing DoctorPh no:Date PrescribedMedication NameDosagePrescribing DoctorPh no:Date PrescribedMedication NameDosagePrescribing DoctorPh no:Date PrescribedMedication NameDosagePrescribing DoctorPh no:Date PrescribedMedication NameDosagePrescribing DoctorPh no:Date PrescribedDoes the person smoke?YesNoNot KnownSection 5a - Threshold Questions checked1Does the person consent to be screened for entry into a Licensed Residential Centre? Yes No2Does person consent to the assessor accessing documents such as medical records and progress notes, and seeking further information from relevant parties such as doctors, nurses and social workers?Yes No3Does person consent to a copy of their Screening Tool assessment being held by ADHC? This will be stored in a secure place and available only to officers involved in working with Licensed Residential Centres.Yes NoIf "No" to questions 1, 2 or 3 Person is not eligible for entry to Licensed Residential Centre - go to Section 6b4Is the person prepared to consider living in a Licensed Residential Centre?Yes NoIf "No" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b5Is the person able to carry out all tasks of personal hygiene? (e.g. washing, dressing). If assistance is needed short term, for example if someone has a broken arm and requires assistance 3 days a week for 1 month only, Home Care may be able to provide support.Yes NoIf "No" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b6Does the person need 24 hour support?Yes NoIf "Yes" Person is not eligible for entry to Licensed Residential Centre - go to Section 6b7What is the risk of the person harming themselves?  High RiskNot Eligible for Entry to an LRC  Medium RiskNot Eligible for Entry to an LRC  Low Risk No Foreseeable Risk8What is the risk of the person harming others? High RiskNot Eligible For Entry to an LRC Medium RiskNot Eligible For Entry to an LRC Low Risk No Foreseeable RiskIf the Questions have been answered as follows:Questions 1 - 3YesQuestion 4 -5YesQuestion 6NoQuestions 7 & 8No Forseeable Risk or Low Riskthen the person may be eligible for entry to an LRC - proceed to Questions at 5bSection 5b - Activities of Daily Living1Is the person able to mobilise independently about the home and community environment without constant physical support by a carer? (May use an aid such as a walking stick and may require episodic assistance or prompting.)YesNo2Is the person able to cut up a meal and feed himself/herself? Must have little or no risk of choking) (may require prompting to attend meals Questions 2 (a) to 2 (j) below are prompt questions to help you determine if a person may be at risk of choking.YesNoIf the answer is "No" to Questions 1 and 2 the Person is not eligible for entry to Licensed Residential Centre - go to Section 6b2 (a)Does the person cough, gag and choke or breathe noisily during or after eating food, drinking or gaking medication? For example: 1. The person sometimes coughs or chokes during or several minutes after eating, drinking or taking medication: 2. The person sometimes coughs or chokes during or several minutes after eating, drinking or taking medication: 3. their breathing becomes noisy after eating or drinking or while talking: 4. The person gags when eating, drinking or taking medication. YesNo2 (b)Does the person have mouth or teeth problems that affect their eating? For example: 1. The person's teeth are lose, broken or missing and affects their ability to chew. 2. The person's lips , tongue, throat or gums are red and inflamed or uncerated. 3.The person has malocclusion (upper and lower teeth do not meet) and this affects their ability to chew. YesNo2 Does the person follow, or are they supposed to follow a 'special diet'? For example: . - Pureed, minced or chopped foods only. - Soft foods only. Suitable 'soft foods' are foods that are well cooked and very little chewing is required. Foods should not require very much cutting if any. Foods should be diced or sliced and should be able to be mashed easily with a fork. - Unsuitable 'soft foods' include those that are hard, stringy, tough or dry. Examples of unsuitable foods are cruncy salads, hard biscuits, grilled meat, nuts, fresh apples, grainy bread and cereals with dried fruit or nuts. YesNo2 (d)Does the person vomit or regurigitate their food on a regular basis? For example: - The person vomits or reguritates (i.e. brings up) food, drink or medication more than once per day or on a regular basis. - The person clears their throat often or burps often. YesNo2 (e)Does the person overfill their mouth or try to eat very quickly? For example: - The person tries to cram or 'stuff' their mouth before attempting to chew or swallow. - The person tries to swallow too much food before they have chewed it properly. - The person usually finishes all of their main meal in less than five minutes. YesNo2 (f)Does the person appear to eat without chewing? For example: - The person sucks their food instead of chewing it. - The food remains in the person's mouth for a long period of time before being swallowed. - The person swallows their food whole without chewing. YesNo2 (g)Does the person show distress during or after eating or drinking? For example: - The person appears distressed while they eat or drink. - The person appears distressed immediately after or shortly after eating or drinking. - Sometime while distressed the person refuses food or spits out food. YesNo2 (h)Does the person select inappropriate foods or behave inappropriately with food? For example: - The person eats non-food items such as dirt, grtass or faeces. - The person steals or hides food. YesNo2 (i)Does food or drink fall out of the person's mouth during eating or drinking? For example: - The person is unable to close their mouth and this causes food, drink or medication to fall out of their mouth. - The person cannont keep their head upright and food, drink or medication falls out of their mouth. - The person's mouth continuously needs to be wiped or they need to wear a cloth to protect their clothes during mealtime. YesNo2 (j)Are there any other swallowing issues that may put the person at risk? For example does he or she have difficulty clearing phlegm or have freuent chest infections or pnemonia? Please make any further comments in space provided below: YesNoIf "Yes" to any of the above prompt questions 2 (a) to 2 (j) the person is not eligible for entry to Licensed Residential Centre - go to Section 6b3Can the person use the toilet independently and manage his/her own continence aids if used? (May have an accident no more than once a month).YesNo4Can the person recognise the need for health care services? (eg medical intervention and visit to the GP).YesNo5Is the person able to communicate his own needs or desires without the use of aids?YesNo6Can the person maintain acceptable behaviour in the community? (That is, behaviour is usually appropriate but may be at risk in social locations or events, or if the person's mental health is unstable).YesNoIf the answer is "No" to Questions 3 to 6 the Person is not eligible for entry to Licensed Residential Centre - go to Section 6b7Can the person manage his or her own bank account and budget? (May need occasional prompts to pay bills).YesNo7.1If the person is unable to manage his or her own bank account do they have support in arranging for assistance as is required to operate their bank account and manage their financial affairs? (Including support in making an application to the Guardianship Tribunal for a financial managment order where necessary before entering an LRC).YesNoIf the answer is "No" to Questions 7 and 7.1 the Person is not eligible for entry to Licensed Residential Centre - go to Section 6b If the answer is "No" to Question 7 and "Yes" to Question 7.1 the person is eligible to enter an LRC.The person is eligible for entry to a LRC if the answers to Threshold Questions were apprpriate. The person is eligbile for entry to a LRC if the answers to Activities of Daily Living Questions 1-2 were YES and the answers to the prompt questions 2 (a) to 2 (j) were NO; and if the answers to Activities of Daily Living Questions 3 to 7 were YES. (In the case of question 7, if the answer to Question 7 was NO, the answer to Question 7.1 must be YES in order to be eligible for an LRC). The person is Not Eligible if any of the answers to Activities of Daily Living Questions 1 to 2 were NO, or if the Prompt questions (regarding choking risks) 2 (a) to 2 (j) were YES. The person is Not Eligible if any of the answers from 3 to 7 are NO; or in the case of question 7 if the answer to questions 7 is NO and the answer of question 7.1 is also NO they are Not Eligible for an LRC.Section 6 - Decision and Action 6AEligible for Entry to LRCIf Eligible, provide the person with letter confirming approval, their copy of the Screening Tool, and list of LRCs.6BNot Eligible for Entry to LRCIf Not Eligible, provide the person with letter advising non-approval, their copy of the Screening Tool, and information about further services that may be available.  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l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytK$$Ifl!vh555#v#v#v:V l4%6+,,,5559/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdp$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5N5555#vN#v#v#v#v:V l8%6,5v55559/ alp2ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l8%6, 555555 5 9 / alpdytK?kd$$Ifl8 P N "X&''''''''''%6((((44 lalpdytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd"$$Ifl P N "X&''''''''''%6((((44 lalpdytK;$$Ifl!vh5 5555555#v #v#v#v#v#v:V l8%6,58 555559/ alpPytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd'$$Ifl P N "X&''''''''''%6((((44 lalpdytKy$IfK$L$!vh5#v:V ,6,59/ 34 p )$$Ifl!vh5555555#v#v#v#v#v#v:V l,%6,5555559/ alpFytKy$IfK$L$!vh5#v:V 6,59/ 34 p m$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd-$$Ifl P N "X&''''''''''%6((((44 lalpdytK;$$Ifl!vh558 555555#v#v8 #v#v#v#v:V l,%6,558 55559/ alpPytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdt2$$Ifl P N "X&''''''''''%6((((44 lalpdytKy$IfK$L$!vh5#v:V ,6,59/ 34 p ;$$Ifl!vh558 555555#v#v8 #v#v#v#v:V l,%6,558 55559/ alpPytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd7$$Ifl P N "X&''''''''''%6((((44 lalpdytKy$IfK$L$!vh5#v:V ,6,59/ 34 p ;$$Ifl!vh558 555555#v#v8 #v#v#v#v:V l,%6,558 55559/ alpPytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdD=$$Ifl P N "X&''''''''''%6((((44 lalpdytKy$IfK$L$!vh5#v:V ,6,59/ 34 p $$Ifl!vh5555#v#v#v#v:V l,%6,55559/ alp(ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdHB$$Ifl P N "X&''''''''''%6((((44 lalpdytK $$Ifl!vh555555#v#v#v#v#v:V l8%6,555559/ alp<ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdG$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh555555#v#v#v#v:V l8%6,55559/ alp<ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l8%6, 555555 5 9 / alpdytK?kdK$$Ifl8 P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh55!#v#v!:V l,%6,55!9/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kdO$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kdBT$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kdX$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd\$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh555555#v#v#v#v:V l8%6,55559/ alp<ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l8%6, 555555 5 9 / alpdytK?kda$$Ifl8 P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh55!#v#v!:V l,%6,55!9/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kde$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5555555#v#v#v#v#v:V l,%6,555559/ alpFytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kdj$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kdn$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd)s$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5 555#v #v#v#v:V l8%6,555559/ alp(ytKM$$Ifl!v h555555555 #v#v#v#v#v#v :V l,%6, 555555 9 / alpZytKkdw$$Ifl, P N X&'''''''''%6$$$$44 lalpZytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd{$$Ifl P N "X&''''''''''%6((((44 lalpdytKk$$Ifl!vh5X&#vX&:V l %65%/ alp ytKM$$Ifl!v h555555555 #v#v#v#v#v#v :V l,%6, 555555 9 / alpZytKkd/$$Ifl, P N X&'''''''''%6$$$$44 lalpZytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l8%6, 555555 5 9 / alpdytK?kd$$Ifl8 P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh55!#v#v!:V l,%6,55!9/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd؆$$Ifl P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5555555#v#v#v#v#v:V l,%6,555559/ alpFytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kd$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l,%6, 555555 5 9 / alpdytK?kd$$Ifl, P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh5P5#vP#v:V l,%6,5x59/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd7$$Ifl P N "X&''''''''''%6((((44 lalpdytK $$Ifl!vh555555#v#v#v#v#v:V lY%6,555559/ alp<ytK$$Ifl!vh555555#v#v#v#v:V l8%6,55559/ alp<ytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l8%6, 555555 5 9 / alpdytK?kd$$Ifl8 P N "X&''''''''''%6((((44 lalpdytK$$Ifl!vh55!#v#v!:V l,%6,55!9/ alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd8$$Ifl P N 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l%6,58 5> 5 9/ / / / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ / / / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ / / / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ / / / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ /  / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ / / / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ /  / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ /  / alpytK$$Ifl!vh5 5> 5 #v #v> #v :V l%6,58 5> 5 9/ /  / alpytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd"$$Ifl P N "X&''''''''''%6((((44 lalpdytK $$Ifl!vh555555#v#v#v#v#v:V l8%6,555559/ alp<ytK;$$Ifl!vh5 5555555#v #v#v#v#v#v:V l8%6,58 555559/ alpPytKm$$Ifl!v h555555555 5 #v#v#v#v#v#v #v :V l%6, 555555 5 9 / alpdytK?kd$$Ifl P N "X&''''''''''%6((((44 lalpdytKy$IfK$L$!vh5#v:V 6,59/ 34 p ;$$Ifl!vh558 555555#v#v8 #v#v#v#v:V l%6,558 55559/ alpPytK$$Ifl!vh558 5#v#v8 #v:V l%6,558 59/ alpytK$$Ifl!vh558 5#v#v8 #v:V l%6,558 59/ alpytK$$Ifl!vh558 5#v#v8 #v:V l%6,558 59/ 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