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Attendant/Child Care Provider Log

Document Number:  DVR-13178

Description:  This form should be completed by individuals providing attendant/child care services for DVR consumers.

Comments:  This form should be printed and completed by hand.

Content Contact:  DVR Forms

Document Attachments:

DVR-13178 (English Print Version - pdf/23 KB)

DVR-13178-S (Spanish Print Version - pdf/26 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.