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Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Detail% Frequency Lab Tests-H-Hemoglobin Al C One Time Lab Tests-C-C8C w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Me

Exp. Dale: Exp. Date: Exp. Date: Exp.. Date: Exp. Date: nrilartiletriailiTtheiii3Oataiiiiiii:Ilii ,77:; .- • Start Date End Date 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. !fla;:a-)ciaetaitat7 - Cleared for Food Service: Yes • No Restrictions Comments: N/A MD 07/3

Cosign encounter performed at HeaIth Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. Beaudouin, Robert MD MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Petailt Frequency Lab Tests-H-Hemoglobin A1C One Time Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Met

equipment ,other. Exp. Date: AYTPREirgEffirelartlitrriTittailiiiTtiziailiiiiciliiitiU ; • Equipment Start Date End Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL tt: P113121313B1ED. WO 110 • Wir .r. s'ziff : :Xie<; . :fr ; • Cleared for Food Service: Yes X No Restrict

Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Beaudouin, Robert MD Freauencv Matt Priority Lab Tests-H-Hemoglobin MC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC

other: Exp. Date: May have the following equipment in his / her possession: Equipment Start Date End Date Return Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A

Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AIC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-

ap. Date: Exp. Date: May have the following equipment in his / her possession: Equipment Start C ite End Date Return Date C-Pap 07 ni 19 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Page 082 of 148 Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions

Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin AlC One Time Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Met

: _football _basketball _handball stationary equipment • falergiffinagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. O W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A 1rtatts:Iriart He

ormed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 MED CL:1 Provider: .... f b_,(6_>; <_b;c_7)(_c > ___ _.I MD NO CCC APPT. Discontinued Laboratory Requests: Details Lab T ests-H-Hemog/obin A 1 C Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab T ests-C-Comprehensive Metabolic Profile (

her: Exp. Date: ------ May have the following equipment in his / her possession: Equipment Start D.:\te End Date Return Date C-Pap 07/30i2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL#: P1 1312813B1 ED. Work Restriction / Limitation: Cleared for Food Service: Yes --- x No Restrictions Comments: N

ake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 MED CL:1 Provider: fbX6>: (b)(7)(C) NO CCC APPT. Discontinued Laboratory Requests: Details Lab T ests-H-Hemog/obin A 1 C Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab T ests-C-Comprehensive Metabolic Profile (

other: Exp. Date: ------ May have the following equipment in his / her possession: Equipment Start Date End Date Return Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL#: P11312813B1ED. Work Restriction / Limitation: Cleared for Food Service: Yes --- x No Restrictions Comments: N/A

Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin AlC One Time Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Met

: _football _basketball _handball stationary equipment • falergiffinagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. O W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A 1rtatts:Iriart He

n Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. =MM. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin AlC One Time Lab Testsi-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests,Comprehensive Metabo

_basketball _handball stationary equipment • falergiffinagra urS areigiga nieig (Mif; •';' Equipment Start Date End Date Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Cleared for Food Service: Yes X No Restrictions Comments: N/A Health Services Staff • Exp. D

Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 R• no Lab Tests-C-CBC w/diff Lab Tests-L-Llpld Pro

ther: _football _basketball _handball stationary equipment • faletanagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A ttiatts:niart Health