Name(必填) 名 姓 Date of Birth(必填)Aide Code(必填)SSNAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Waiving Health Coverage(必填) I am covered under another group plan as a spouse or dependent I am covered by Medicaid, Medicare, or Veterans Program I am covered under a health insurance plan sponsored by second employer I am covered through a non-group, individual or private health care plan not offered through my employer I don't wish to participate in health care benefits at this time (I am declining health insurance entirely)Initial(必填)Signature(必填)HiddenAdministrative StuffHiddenRN Evaluator 名 姓 HiddenRN InitialHiddenLIC. NumberHiddenAide PositionHiddenHEP B Vaccination Yes, I accept vaccination No, I decline vaccination
