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Atory. When completed and on file, it meets the requirements of DCF 250.04(5)(e) and DCF 251.05(1)(L)1. of the Wisconsin Administrative Code. Failure to obtain a completed form for placement in the staff file may result in enforcement action. Personal information you provide may be used for secondary purposes Privacy Law, s.15.04(1)(m), Wisconsin Statutes . Instructions: The examining health professional will complete this form, sign Sections B and C and return the completed form to the child c.

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