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By the licensee and resident, or the resident s designated representative. The responsible agency, if any, may assist in this process. Use additional sheets if necessary and PRINT CLEARLY. Name of Resident Name of Designated Representative (if applicable) Date of Birth Sex M I. SOCIAL/BEHAVIORAL ASSESSMENT Yes F PLAN OF ACTION (Check Yes or No and Complete Where Appropriate) No IF NO, Describe Needs and How They Will Be Met A. Moves Independently in Community B. Communicates Needs C.

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