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494.382 284.134 ] /Subtype /Widget /TU (How many outpatients had other public insurance?) /F 4 /P 7170 0 R /Q 1 /T (6b) /StructParent 3452 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7247 0 R /K 7245 0 R >> /Ff 8388608 /AP << /N 7243 0 R >> >> endobj 7186 0 obj << /Rect [ 72.472 101.55 585.394 132.449 ] /Subtype /Widget /TU (If yes, please explain why your hospital denied medical services to any individuals with Medicare.) /F 4 /P 7170 0 R /T (FillText61) /StructParent 3464 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7252 0 R >> >> endobj 7187 0 obj << /Rect [ 52.809 464.472 62.9214 475.146 ] /Subtype /Widget /TU (Heart is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1h) /StructParent 3451 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7333 0 R /Off 7335 0 R >> /N << /Yes 7336 0 R >> >> /AS /Off >> endobj 7188 0 obj << /Rect [ 72.472 41.4377 585.394 72.3366 ] /Subtype /Widget /TU (If yes, please explain why your hospital denied medical services to any individuals with Medicaid.) /F 4 /P 7170 0 R /T (FillText62) /StructParent 3454 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7260 0 R >> >> endobj 7189 0 obj << /Rect [ 52.809 476.831 62.9214 488.067 ] /Subtype /Widget /TU (Cancer is the category that best described your hospital or the type of service it provided to the majority of admissions. 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CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1r) /StructParent 3462 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7288 0 R /Off 7286 0 R >> /N << /Yes 7285 0 R >> >> /AS /Off >> endobj 7197 0 obj << /Rect [ 306.742 312.786 403.371 325.146 ] /Subtype /Widget /TU (How many inpatients had Medicare?) /F 4 /P 7170 0 R /Q 1 /T (4a) /StructParent 3491 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7297 0 R /K 7312 0 R >> /Ff 8388608 /AP << /N 7327 0 R >> >> endobj 7198 0 obj << /Rect [ 353.933 476.831 364.045 488.067 ] /Subtype /Widget /TU (Acute long-term care is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1q) /StructParent 3463 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7291 0 R /Off 7290 0 R >> /N << /Yes 7289 0 R >> >> /AS /Off >> endobj 7199 0 obj << /Rect [ 353.933 489.753 364.045 500.427 ] /Subtype /Widget /TU (Institution for the mentally retarded is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1p) /StructParent 3486 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7299 0 R /Off 7295 0 R >> /N << /Yes 7293 0 R >> >> /AS /Off >> endobj 7200 0 obj << /Rect [ 353.933 502.112 364.045 513.348 ] /Subtype /Widget /TU (Chronic disease is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1o) /StructParent 3468 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7317 0 R /Off 7307 0 R >> /N << /Yes 7302 0 R >> >> /AS /Off >> endobj 7201 0 obj << /Rect [ 353.933 514.472 364.045 525.708 ] /Subtype /Widget /TU (Orthopedic is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1n) /StructParent 3467 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7332 0 R /Off 7322 0 R >> /N << /Yes 7319 0 R >> >> /AS /Off >> endobj 7202 0 obj << /Rect [ 26.9663 621.213 306.742 634.696 ] /Subtype /Widget /TU (Name of Hospital) /F 4 /P 7170 0 R /T (HospitalName) /StructParent 3444 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7292 0 R >> >> endobj 7203 0 obj << /Rect [ 403.371 312.786 494.382 325.146 ] /Subtype /Widget /TU (How many outpatients had Medicare?) /F 4 /P 7170 0 R /Q 1 /T (4b) /StructParent 3490 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7354 0 R /K 7349 0 R >> /Ff 8388608 /AP << /N 7344 0 R >> >> endobj 7204 0 obj << /Rect [ 306.742 621.213 410.113 634.696 ] /Subtype /Widget /TU (Hospital's E.I.N.) /F 4 /P 7170 0 R /Q 1 /T (EIN) /StructParent 3446 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7294 0 R >> >> endobj 7205 0 obj << /Rect [ 353.933 527.393 364.045 538.629 ] /Subtype /Widget /TU (Rehabilitation is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1m) /StructParent 3457 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7342 0 R /Off 7339 0 R >> /N << /Yes 7337 0 R >> >> /AS /Off >> endobj 7206 0 obj << /Rect [ 410.113 621.213 585.394 634.696 ] /Subtype /Widget /TU (Hospital's Most Recently Completed Tax Period) /F 4 /P 7170 0 R /Q 1 /T (MostRecentCompTaxPeriod) /StructParent 3448 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7296 0 R >> >> endobj 7207 0 obj << /Rect [ 353.933 540.314 364.045 550.989 ] /Subtype /Widget /TU (Eye, ear, nose and throat is the category that best described your hospital or the type of service it provided to the majority of admissions. 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CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1k) /StructParent 3487 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7348 0 R /Off 7350 0 R >> /N << /Yes 7351 0 R >> >> /AS /Off >> endobj 7210 0 obj << /Rect [ 403.371 290.876 494.382 305.483 ] /Subtype /Widget /TU (How many outpatients had Medicaid?) /F 4 /P 7170 0 R /Q 1 /T (5b) /StructParent 3477 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7265 0 R /K 7263 0 R >> /Ff 8388608 /AP << /N 7261 0 R >> >> endobj 7211 0 obj << /Rect [ 52.809 438.067 62.9214 448.741 ] /Subtype /Widget /TU (Organization is not a 501\(c\)\(3\) hospital. If you checked this box, stop here and return the questionnatire to us. 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CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1c) /StructParent 3460 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7308 0 R /Off 7310 0 R >> /N << /Yes 7311 0 R >> >> /AS /Off >> endobj 7215 0 obj << /Rect [ 52.809 450.989 62.9214 461.663 ] /Subtype /Widget /TU (Alcoholism and other chemical dependency is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1i) /StructParent 3476 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7338 0 R /Off 7340 0 R >> /N << /Yes 7341 0 R >> >> /AS /Off >> endobj 7216 0 obj << /Rect [ 52.809 515.034 62.9214 526.269 ] /Subtype /Widget /TU (Surgical is the category that best described your hospital or the type of service it provided to the majority of admissions. CHECK ONLY ONE BOX.) /F 4 /H /T /P 7170 0 R /T (II1d) /StructParent 3465 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7313 0 R /Off 7315 0 R >> /N << /Yes 7316 0 R >> >> /AS /Off >> endobj 7217 0 obj << /Rect [ 494.382 333.011 585.394 346.494 ] /Subtype /Widget /TU (How many emergency room patients had private insurance?) /F 4 /P 7170 0 R /Q 1 /T (3c) /StructParent 3492 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7268 0 R /K 7279 0 R >> /Ff 8388608 /AP << /N 7287 0 R >> >> endobj 7218 0 obj << /Rect [ 53.3708 502.112 63.4832 513.348 ] /Subtype /Widget /TU (Psychiatric is the category that best described your hospital or the type of service it provided to the majority of admissions. 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/AP << /N 7432 0 R >> >> endobj 7366 0 obj << /Rect [ 60.1124 148.179 85.3933 162.224 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in business.) /F 4 /P 7355 0 R /Q 1 /T (FillText82) /StructParent 3418 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7441 0 R /K 7439 0 R >> /Ff 8388608 /AP << /N 7438 0 R >> >> endobj 7367 0 obj << /Rect [ 376.966 148.179 402.247 162.224 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in religion.) /F 4 /P 7355 0 R /Q 1 /T (FillText75) /StructParent 3412 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7498 0 R /K 7419 0 R >> /Ff 8388608 /AP << /N 7427 0 R >> >> endobj 7368 0 obj << /Rect [ 60.1124 161.101 85.3933 175.146 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in banking/finance.) /F 4 /P 7355 0 R /Q 1 /T (FillText83) /StructParent 3735 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7446 0 R /K 7445 0 R >> /Ff 8388608 /AP << /N 7443 0 R >> >> endobj 7369 0 obj << /Rect [ 60.1124 174.022 85.3933 187.505 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in accounting.) /F 4 /P 7355 0 R /Q 1 /T (FillText84) /StructParent 3736 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7451 0 R /K 7450 0 R >> /Ff 8388608 /AP << /N 7449 0 R >> >> endobj 7370 0 obj << /Rect [ 282.023 217.281 585.394 230.202 ] /Subtype /Widget /TU (How many directors were on your hospital's board of directors?) /F 4 /P 7355 0 R /T (FillText66) /StructParent 3740 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7457 0 R /K 7455 0 R >> /Ff 8388608 /AP << /N 7454 0 R >> >> endobj 7371 0 obj << /Rect [ 52.2472 261.101 585.394 294.247 ] /Subtype /Widget /TU (If yes, please explain why your hospital's emergency room denied services to any individuals that requested such services?) /F 4 /P 7355 0 R /T (FillText65) /StructParent 3741 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7459 0 R >> >> endobj 7372 0 obj << /Rect [ 375.843 136.382 402.247 149.303 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in retail.) /F 4 /P 7355 0 R /Q 1 /T (FillText113) /StructParent 3733 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7435 0 R /K 7444 0 R >> /Ff 8388608 /AP << /N 7448 0 R >> >> endobj 7373 0 obj << /Rect [ 556.742 312.224 566.854 322.899 ] /Subtype /Widget /TU (Check no if your hospital's emergency room did not deny services to any individuals that requested such services.) /F 4 /H /T /P 7355 0 R /T (cb14No) /StructParent 3745 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7467 0 R /Off 7464 0 R >> /N << /Yes 7463 0 R >> >> /AS /Off >> endobj 7374 0 obj << /Rect [ 507.866 312.224 517.978 322.337 ] /Subtype /Widget /TU (Check yes if your hospital's emergency room denied services to any individuals that requested such services.) /F 4 /H /T /P 7355 0 R /T (cb14Yes) /StructParent 3748 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7473 0 R /Off 7471 0 R >> /N << /Yes 7469 0 R >> >> /AS /Off >> endobj 7375 0 obj << /Rect [ 52.2472 329.078 585.394 363.348 ] /Subtype /Widget /TU (If no, please explain why your hospital's emergency room doesn't provide services to all members of the communirty regardless of their ability to pay.) /F 4 /P 7355 0 R /T (FillText64) /StructParent 3750 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7477 0 R >> >> endobj 7376 0 obj << /Rect [ 108.989 379.64 119.101 390.876 ] /Subtype /Widget /TU (Check no if your hospital's emergency room did not provide services to all members of the community regardless of their ability to pay.) /F 4 /H /T /P 7355 0 R /T (cb13No) /StructParent 3753 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7483 0 R /Off 7481 0 R >> /N << /Yes 7479 0 R >> >> /AS /Off >> endobj 7377 0 obj << /Rect [ 375.843 123.46 402.247 137.505 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in social services.) /F 4 /P 7355 0 R /Q 1 /T (FillText114) /StructParent 3426 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7519 0 R /K 7526 0 R >> /Ff 8388608 /AP << /N 7500 0 R >> >> endobj 7378 0 obj << /Rect [ 60.6742 380.202 70.7866 391.438 ] /Subtype /Widget /TU (Check yes if your hospital's emergency room provide services to all members of the community regardless of their ability to pay.) /F 4 /H /T /P 7355 0 R /T (cb13Yes) /StructParent 3757 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7490 0 R /Off 7487 0 R >> /N << /Yes 7486 0 R >> >> /AS /Off >> endobj 7379 0 obj << /Rect [ 375.843 111.101 402.247 124.022 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background other than those listed.) /F 4 /P 7355 0 R /Q 1 /T (FillText115) /StructParent 3424 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7502 0 R /K 7507 0 R >> /Ff 8388608 /AP << /N 7509 0 R >> >> endobj 7380 0 obj << /Rect [ 320.225 415.034 506.18 429.078 ] /Subtype /Widget /TU (Please describe other level of trauma center certification.) /F 4 /P 7355 0 R /T (FillText63) /StructParent 3759 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7493 0 R >> >> endobj 7381 0 obj << /Rect [ 185.393 416.157 196.629 426.831 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is something other than those listed here.) /F 4 /H /T /P 7355 0 R /T (cb12zf) /StructParent 3762 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7499 0 R /Off 7497 0 R >> /N << /Yes 7495 0 R >> >> /AS /Off >> endobj 7382 0 obj << /Rect [ 215.169 123.46 239.888 136.382 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in manufacturing.) /F 4 /P 7355 0 R /Q 1 /T (FillText71) /StructParent 3760 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7458 0 R /K 7461 0 R >> /Ff 8388608 /AP << /N 7465 0 R >> >> endobj 7383 0 obj << /Rect [ 478.09 113.348 585.394 126.269 ] /Subtype /Widget /TU (Specify other professional background\(s\) of directors.) /F 4 /P 7355 0 R /T (FillText85) /StructParent 3410 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7516 0 R >> >> endobj 7384 0 obj << /Rect [ 185.955 444.809 197.191 455.483 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is Level IV) /F 4 /H /T /P 7355 0 R /T (cb12zd) /StructParent 3404 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7513 0 R /Off 7511 0 R >> /N << /Yes 7436 0 R >> >> /AS /Off >> endobj 7385 0 obj << /Rect [ 59.5506 418.404 70.7866 429.078 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is Level III) /F 4 /H /T /P 7355 0 R /T (cb12zc) /StructParent 3407 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7524 0 R /Off 7456 0 R >> /N << /Yes 7452 0 R >> >> /AS /Off >> endobj 7386 0 obj << /Rect [ 59.5506 431.326 70.7866 442 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is Level II) /F 4 /H /T /P 7355 0 R /T (cb12zb) /StructParent 3414 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7440 0 R /Off 7539 0 R >> /N << /Yes 7476 0 R >> >> /AS /Off >> endobj 7387 0 obj << /Rect [ 61.236 79.0782 71.9102 89.1906 ] /Subtype /Widget /TU (Check here if the Board of Directors met monthly.) /F 4 /H /T /P 7355 0 R /T (cb17M) /StructParent 3405 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Monthly 7518 0 R /Off 7523 0 R >> /N << /Monthly 7530 0 R >> >> /AS /Off >> endobj 7388 0 obj << /Rect [ 60.1124 445.371 71.3484 456.045 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is Level I) /F 4 /H /T /P 7355 0 R /T (cb12za) /StructParent 3422 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7508 0 R /Off 7506 0 R >> /N << /Yes 7505 0 R >> >> /AS /Off >> endobj 7389 0 obj << /Rect [ 162.921 79.0782 173.596 89.1906 ] /Subtype /Widget /TU (Check here if the Board of Directors met quarterly.) /F 4 /H /T /P 7355 0 R /T (cb17Q) /StructParent 3763 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Quarterly 7531 0 R /Off 7533 0 R >> /N << /Quarterly 7538 0 R >> >> /AS /Off >> endobj 7390 0 obj << /Rect [ 382.023 478.517 392.135 489.753 ] /Subtype /Widget /TU (Check no if your hospital's emergency room does not have a trauma center.) /F 4 /H /T /P 7355 0 R /T (cb11No) /StructParent 3428 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7517 0 R /Off 7515 0 R >> /N << /No 7510 0 R >> >> /AS /Off >> endobj 7391 0 obj << /Rect [ 333.146 479.078 343.259 490.314 ] /Subtype /Widget /TU (Check yes if your hospital's emergency room has a trauma center.) /F 4 /H /T /P 7355 0 R /T (cb11Yes) /StructParent 3420 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7411 0 R /Off 7522 0 R >> /N << /Yes 7521 0 R >> >> /AS /Off >> endobj 7392 0 obj << /Rect [ 189.888 498.18 585.394 511.101 ] /Subtype /Widget /TU (Explain if emergency room's hours of operation is anything other than 24 hours a day, 365 days a year.) /F 4 /P 7355 0 R /T (FillText56) /StructParent 3416 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7532 0 R >> >> endobj 7393 0 obj << /Rect [ 265.73 78.5164 276.405 88.6288 ] /Subtype /Widget /TU (Check here if the Board of Directors met annually.) /F 4 /H /T /P 7355 0 R /T (cb17A) /StructParent 3758 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Annually 7542 0 R /Off 7543 0 R >> /N << /Annually 7546 0 R >> >> /AS /Off >> endobj 7394 0 obj << /Rect [ 60.1124 502.112 71.3484 512.225 ] /Subtype /Widget /TU (Check here if the emergency room's hours of operation was anything other than 24 hours a day, 365 days a year.) /F 4 /H /T /P 7355 0 R /T (cb10-2) /StructParent 3408 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7540 0 R /Off 7537 0 R >> /N << /Yes 7534 0 R >> >> /AS /Off >> endobj 7395 0 obj << /Rect [ 60.1124 515.034 71.3484 525.146 ] /Subtype /Widget /TU (Check here if the emergency room's hours of operation was 24 hours a day, 365 days a year.) /F 4 /H /T /P 7355 0 R /T (cb10-1) /StructParent 3403 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7545 0 R /Off 7544 0 R >> /N << /Yes 7536 0 R >> >> /AS /Off >> endobj 7396 0 obj << /Rect [ 52.2472 543.123 585.394 576.269 ] /Subtype /Widget /TU (If no, please explain why your hospital doesn't operate an emergency room?) /F 4 /P 7355 0 R /T (FillText57) /StructParent 3766 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7547 0 R >> >> endobj 7397 0 obj << /Rect [ 60.6742 65.5951 71.3484 75.7074 ] /Subtype /Widget /TU (Check here if thet board of directors met on some other basis than those listed above.) /F 4 /H /T /P 7355 0 R /T (cb17O) /StructParent 3751 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Other 7548 0 R /Off 7549 0 R >> /N << /Other 7527 0 R >> >> /AS /Off >> endobj 7398 0 obj << /Rect [ 326.405 594.247 337.641 604.359 ] /Subtype /Widget /TU (Check no if your hospital did not operate an emergency room.) /F 4 /H /T /P 7355 0 R /T (cb9No) /StructParent 3761 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7529 0 R /Off 7550 0 R >> /N << /No 7551 0 R >> >> /AS /Off >> endobj 7399 0 obj << /Rect [ 278.09 594.247 289.326 604.359 ] /Subtype /Widget /TU (Check yes if your hospital operated an emergency room.) /F 4 /H /T /P 7355 0 R /T (cb9Yes) /StructParent 3756 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7512 0 R /Off 7520 0 R >> /N << /Yes 7525 0 R >> >> /AS /Off >> endobj 7400 0 obj << /Rect [ 71.9102 631.326 585.394 666.157 ] /Subtype /Widget /TU (If yes, please explain why your hospital denied medical services to any individuals with no insurance.) /F 4 /P 7355 0 R /T (FillText58) /StructParent 3754 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7501 0 R >> >> endobj 7401 0 obj << /Rect [ 194.944 66.1569 410.113 79.0782 ] /Subtype /Widget /TU (Please describe how often the board of directors meet if Other is checked.) /F 4 /P 7355 0 R /T (FillText90) /StructParent 3746 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 7514 0 R >> >> endobj 7402 0 obj << /Rect [ 238.764 682.449 248.315 692.562 ] /Subtype /Widget /TU (Check no if your hospital did not deny medical services to any individuals with no insurance.) /F 4 /H /T /P 7355 0 R /T (cb8eNo) /StructParent 3749 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7492 0 R /Off 7412 0 R >> /N << /No 7413 0 R >> >> /AS /Off >> endobj 7403 0 obj << /Rect [ 189.888 683.011 199.438 693.123 ] /Subtype /Widget /TU (Check yes if your hospital denied medical services to any individuals with no insurance.) /F 4 /H /T /P 7355 0 R /T (cb8eYes) /StructParent 3744 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7484 0 R /Off 7488 0 R >> /N << /Yes 7535 0 R >> >> /AS /Off >> endobj 7404 0 obj << /Rect [ 71.9102 697.056 585.394 734.135 ] /Subtype /Widget /TU (If yes, please explain why your hospital denied medical services to any individuals with other public health insurance.) /F 4 /P 7355 0 R /T (FillText59) /StructParent 3742 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7480 0 R >> >> endobj 7405 0 obj << /Rect [ 367.978 45.3703 584.27 58.2917 ] /Subtype /Widget /TU (On average, how many directors were present at each meeting?) /F 4 /P 7355 0 R /T (FillText116) /StructParent 3739 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7504 0 R /K 7541 0 R >> /Ff 8388608 /AP << /N 7496 0 R >> >> endobj 7406 0 obj << /Rect [ 273.034 750.989 283.146 761.101 ] /Subtype /Widget /TU (Check no if your hospital did not deny medical services to any individuals with other public health insurance.) /F 4 /H /T /P 7355 0 R /T (cb8dNo) /StructParent 3737 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7470 0 R /Off 7474 0 R >> /N << /No 7528 0 R >> >> /AS /Off >> endobj 7407 0 obj << /Rect [ 225.281 750.989 235.393 761.101 ] /Subtype /Widget /TU (Check yes if your hospital denied medical services to any individuals with other public health insurance.) /F 4 /H /T /P 7355 0 R /T (cb8dYes) /StructParent 3732 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7460 0 R /Off 7462 0 R >> /N << /Yes 7466 0 R >> >> /AS /Off >> endobj 7408 0 obj << /Rect [ 186.517 430.202 197.753 440.876 ] /Subtype /Widget /TU (If yes to question 11, check here if the trauma center's level of certification is Level V) /F 4 /H /T /P 7355 0 R /T (cb12ze) /StructParent 3765 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7431 0 R /Off 7503 0 R >> /N << /Yes 7423 0 R >> >> /AS /Off >> endobj 7409 0 obj << /Rect [ 215.169 161.101 239.888 174.022 ] /Subtype /Widget /TU (Please indicate the number of directors with a professional background in insurance.) /F 4 /P 7355 0 R /Q 1 /T (FillText68) /StructParent 3747 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 7414 0 R /K 7415 0 R >> /Ff 8388608 /AP << /N 7420 0 R >> >> endobj 7410 0 obj << /Length 5437 /Filter /FlateDecode >> stream HWn}WZ 6"pba/ٱ_v;(S30g-ի7obgOg7[Eo={ܝ]^H Q(= ߟ`(~@D@ţ"^و u!z PA\p1"Q@yUdk;P"D9{g8էp0 885ƺIP 5 W848 0f z> AJCPs6^yF5u ^WT.,vs'˻,,j>ɐ8L&hS o fXt(Cm[C#*ӇFEeC@TL:TX})KT)RDAIs$8׭37iftwHŇ#tFYKԄ@8G tw)+ ?p [khYApz-B҃*3*HzR=&}.[BZQ@  I@RBKуizYqk+(F< 8*J !踑9pp ɠjrʡ@95AQ^¡ġ11[EXխHHl}m99aV`c"ެ  }򙁤|@kF`~1J;F䊑j~e?̾s2^)Ǐ5bxx,Ǐ\9@pcs 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compensation more than 90 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42b4) /StructParent 3681 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7863 0 R /Off 7862 0 R >> /N << /1 7861 0 R >> >> /AS /Off >> endobj 7783 0 obj << /Rect [ 318.539 355.483 329.214 367.842 ] /Subtype /Widget /TU (Our hospital determined that it would provide inpatient services to any individiual without compensation 30 to 90 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42a3) /StructParent 3683 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7892 0 R /Off 7890 0 R >> /N << /1 7888 0 R >> >> /AS /Off >> endobj 7784 0 obj << /Rect [ 239.326 355.483 250.562 367.842 ] /Subtype /Widget /TU (Our hospital determined that it would provide inpatient services to any individiual without compensation less than 30 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42a2) /StructParent 3687 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot 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367.842 ] /Subtype /Widget /TU (Our hospital determined that it would provide inpatient services to any individiual without compensation at or before providing services.) /F 4 /H /T /P 7780 0 R /T (42a1) /StructParent 3668 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7902 0 R /Off 7901 0 R >> /N << /1 7899 0 R >> >> /AS /Off >> endobj 7788 0 obj << /Rect [ 239.326 337.505 250.562 349.865 ] /Subtype /Widget /TU (Our hospital determined that it would provide outpatient services to any individiual without compensation less than 30 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42b2) /StructParent 3651 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7869 0 R /Off 7868 0 R >> /N << /1 7867 0 R >> >> /AS /Off >> endobj 7789 0 obj << /Rect [ 239.326 312.786 250.562 324.584 ] /Subtype /Widget /TU (Our hospital determined that it would provide emergency room services to any individiual without compensation less than 30 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42c2) /StructParent 3677 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7848 0 R /Off 7847 0 R >> /N << /1 7846 0 R >> >> /AS /Off >> endobj 7790 0 obj << /Rect [ 395.506 312.786 406.18 324.584 ] /Subtype /Widget /TU (Our hospital determined that it would provide emerency room services to any individiual without compensation more than 90 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42c4) /StructParent 3675 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7841 0 R /Off 7840 0 R >> /N << /1 7835 0 R >> >> /AS /Off >> endobj 7791 0 obj << /Rect [ 549.438 337.505 561.236 349.865 ] /Subtype /Widget /TU (Our hospital determined that it would provide outpatient services to any individiual without compensation at an other time \(explain below\)) /F 4 /H /T /P 7780 0 R /T (42b6) /StructParent 3673 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << 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hospital determined that it would provide outpatient services to any individiual without compensation when insurance denied all or part of claim.) /F 4 /H /T /P 7780 0 R /T (42b5) /StructParent 3670 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7860 0 R /Off 7858 0 R >> /N << /1 7856 0 R >> >> /AS /Off >> endobj 7795 0 obj << /Rect [ 477.528 312.786 488.203 324.584 ] /Subtype /Widget /TU (Our hospital determined that it would provide emergency room services to any individiual without compensation when insurance denied all or part of claim.) /F 4 /H /T /P 7780 0 R /T (42c5) /StructParent 3672 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7825 0 R /Off 7837 0 R >> /N << /1 7824 0 R >> >> /AS /Off >> endobj 7796 0 obj << /Rect [ 395.506 355.483 406.18 367.842 ] /Subtype /Widget /TU (Our hospital determined that it would provide inpatient services to any individiual without compensation more than 90 days after providing services.) /F 4 /H /T /P 7780 0 R /T (42a4) /StructParent 3676 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7887 0 R /Off 7886 0 R >> /N << /1 7885 0 R >> >> /AS /Off >> endobj 7797 0 obj << /Rect [ 477.528 355.483 488.203 367.842 ] /Subtype /Widget /TU (Our hospital determined that it would provide inpatient services to any individiual without compensation when insurance denied all or part of claim.) /F 4 /H /T /P 7780 0 R /T (42a5) /StructParent 3665 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 7883 0 R /Off 7882 0 R >> /N << /1 7881 0 R >> >> /AS /Off >> endobj 7798 0 obj << /Rect [ 441.573 541.438 452.809 552.112 ] /Subtype /Widget /TU (Check no if your hospital did not provide emergency room services to any individual without compensation.) /F 4 /H /T /P 7780 0 R /T (cb41cNo) /StructParent 3652 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7897 0 R /Off 7903 0 R >> /N << /No 7908 0 R >> 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such services.) /F 4 /H /T /P 7915 0 R /T (cb56No) /StructParent 3415 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 7948 0 R /Off 7946 0 R >> /N << /No 7945 0 R >> >> /AS /Off >> endobj 7927 0 obj << /Rect [ 410.113 459.415 420.787 468.966 ] /Subtype /Widget /TU (Check yes if your hospital charged all patients the same price for the same services.) /F 4 /H /T /P 7915 0 R /T (cb52Yes) /StructParent 3430 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 7980 0 R /Off 7984 0 R >> /N << /Yes 7986 0 R >> >> /AS /Off >> endobj 7928 0 obj << /Rect [ 51.1236 45.9321 585.955 100.988 ] /Subtype /Widget /TU (Please explain.) /F 4 /P 7915 0 R /T (FillText191) /StructParent 3417 /V () /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8392704 /AP << /N 7942 0 R >> >> endobj 7929 0 obj << /Rect [ 514.045 479.078 584.27 493.123 ] /Subtype /Widget /TU (How many days after a patient had not paid all or part of a bill did your hospital classify it 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/Rect [ 171.348 214.472 181.461 225.708 ] /Subtype /Widget /TU (The Board of Directors in your hospital set the compensation for officers, directors, trustees, and key employees.) /F 4 /H /T /P 8137 0 R /T (IIIcb4b) /StructParent 3620 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8261 0 R /Off 8260 0 R >> /N << /Yes 8258 0 R >> >> /AS /Off >> endobj 8157 0 obj << /Rect [ 63.4832 164.471 74.7192 174.584 ] /Subtype /Widget /TU (Published surveys of compensation at similar institutions were used to determine compensation amounts.) /F 4 /H /T /P 8137 0 R /T (IIIcb5a) /StructParent 3577 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8240 0 R /Off 8237 0 R >> /N << /Yes 8235 0 R >> >> /AS /Off >> endobj 8158 0 obj << /Rect [ 352.247 436.382 454.495 455.483 ] /Subtype /Widget /TU (Salary - Line 4) /F 4 /P 8137 0 R /Q 1 /T (III1SalaryLine4) /StructParent 3614 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 8307 0 R /K 8303 0 R >> /Ff 8388608 /AP << /N 8301 0 R >> >> endobj 8159 0 obj << /Rect [ 454.495 341.438 584.27 360.539 ] /Subtype /Widget /TU (Other Compensation - Line 9) /F 4 /P 8137 0 R /Q 1 /T (FillText240) /StructParent 3597 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 8249 0 R /K 8252 0 R >> /Ff 8388608 /AP << /N 8222 0 R >> >> endobj 8160 0 obj << /Rect [ 352.247 379.64 454.495 398.18 ] /Subtype /Widget /TU (Salary - Line 7) /F 4 /P 8137 0 R /Q 1 /T (FillText231) /StructParent 3610 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 8223 0 R /K 8262 0 R >> /Ff 8388608 /AP << /N 8251 0 R >> >> endobj 8161 0 obj << /Rect [ 63.4832 214.472 74.7192 225.708 ] /Subtype /Widget /TU (\376\377Officers in your hospital set the compensation for officers, directors, trustees, and key employees.) /F 4 /H /T /P 8137 0 R /T (IIIcb4a) /StructParent 3572 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8269 0 R /Off 8268 0 R >> /N << /Yes 8266 0 R >> >> /AS /Off >> endobj 8162 0 obj << /Rect [ 223.596 360.539 352.247 379.64 ] /Subtype /Widget /TU (Title - Line 8) /F 4 /P 8137 0 R /Q 1 /T (FillText234) /StructParent 3602 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 8214 0 R >> >> endobj 8163 0 obj << /Rect [ 63.4832 149.303 74.7192 159.415 ] /Subtype /Widget /TU (Internet research on compensation at similar institutions conducted by your employees were used to determine compensation amounts.) /F 4 /H /T /P 8137 0 R /T (IIIcb5b) /StructParent 3575 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8232 0 R /Off 8230 0 R >> /N << /Yes 8229 0 R >> >> /AS /Off >> endobj 8164 0 obj << /Rect [ 406.742 279.64 416.292 290.876 ] /Subtype /Widget /TU (Check no if your hospital did not have a formal written compensation policy.) /F 4 /H /T /P 8137 0 R /T (IIIcb2No) /StructParent 3570 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 8234 0 R /Off 8242 0 R >> /N << /No 8247 0 R >> >> /AS 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/N 8212 0 R >> >> endobj 8168 0 obj << /Rect [ 223.596 436.382 352.247 455.483 ] /Subtype /Widget /TU (Title - Line 4) /F 4 /P 8137 0 R /Q 1 /T (III1TitleLine4) /StructParent 3612 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 8314 0 R >> >> endobj 8169 0 obj << /Rect [ 195.506 62.2243 584.27 75.7074 ] /Subtype /Widget /TU (Describe other methods of determining hospital compensation amounts.) /F 4 /P 8137 0 R /T (FillText241) /StructParent 3559 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 8197 0 R >> >> endobj 8170 0 obj << /Rect [ 63.4832 62.2243 74.7192 72.3366 ] /Subtype /Widget /TU (Other reason\(s\) were used to determine compensation amounts.) /F 4 /H /T /P 8137 0 R /T (IIIcb4g) /StructParent 3561 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8207 0 R /Off 8203 0 R >> /N << /Yes 8201 0 R >> >> /AS /Off >> endobj 8171 0 obj << /Rect [ 63.4832 133.573 74.7192 144.247 ] /Subtype /Widget /TU (Phone survey\(s\) of compensation at similar institutions conducted by your hospital's employees were used to determine compensation amounts.) /F 4 /H /T /P 8137 0 R /T (IIIcb5c) /StructParent 3569 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /Yes 8259 0 R /Off 8219 0 R >> /N << /Yes 8216 0 R >> >> /AS /Off >> endobj 8172 0 obj << /Rect [ 454.495 455.483 584.27 474.584 ] /Subtype /Widget /TU (Other Compensation - Line 3) /F 4 /P 8137 0 R /Q 1 /T (III1OtherCompLine3) /StructParent 3579 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 8318 0 R /K 8317 0 R >> /Ff 8388608 /AP << /N 8316 0 R >> >> endobj 8173 0 obj << /Rect [ 50.5618 341.438 223.596 360.539 ] /Subtype /Widget /TU (Name - Line 9) /F 4 /P 8137 0 R /T (FillText237) /StructParent 3624 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 8209 0 R >> >> endobj 8174 0 obj << /Rect [ 454.495 436.382 584.27 455.483 ] /Subtype /Widget /TU (Other Compensation - Line 4) /F 4 /P 8137 0 R /Q 1 /T (III1OtherCompLine4) /StructParent 3584 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /AA << /F 8294 0 R /K 8305 0 R >> /Ff 8388608 /AP << /N 8312 0 R >> >> endobj 8175 0 obj << /Rect [ 223.596 455.483 352.247 474.584 ] /Subtype /Widget /TU (Title - Line 3) /F 4 /P 8137 0 R /Q 1 /T (III1TitleLine3) /StructParent 3567 /DA (/Helv 10 Tf 0 g) /FT /Tx /Type /Annot /Ff 8388608 /AP << /N 8278 0 R >> >> endobj 8176 0 obj << /Rect [ 116.292 735.82 127.528 747.056 ] /Subtype /Widget /TU (Check no if your hospital does not have any other programs or activities that promoted health for the benefit of the community.) /F 4 /H /T /P 8137 0 R /T (cb72No) /StructParent 3606 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /No 8287 0 R /Off 8311 0 R >> /N << /No 8308 0 R >> >> /AS /Off >> endobj 8177 0 obj << /Rect [ 454.495 398.18 584.27 417.281 ] /Subtype /Widget /TU (Other Compensation - Line 6) /F 4 /P 8137 0 R /Q 1 /T (III1OtherCompLine6) /StructParent 3598 /DA (/Helv 10 Tf 0 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used for all paragraph 4958\(f\)\(4\) employees?) /F 4 /H /T /P 8322 0 R /T (IIIcb6hYes) /StructParent 3686 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 8416 0 R /Off 8415 0 R >> /N << /1 8414 0 R >> >> /AS /Off >> endobj 8361 0 obj << /Rect [ 525.843 624.584 547.191 637.505 ] /Subtype /Widget /TU (Check no if Services of a Similar Nature Provided is not a comparability factor used for all paragraph 4958\(f\)\(4\) employees.) /F 4 /H /T /P 8322 0 R /T (IIIcb6hNo) /StructParent 3680 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot /MK << /CA (4) >> /AP << /D << /1 8411 0 R /Off 8471 0 R >> /N << /1 8409 0 R >> >> /AS /Off >> endobj 8362 0 obj << /Rect [ 333.708 608.292 355.056 624.022 ] /Subtype /Widget /TU (Check yes if Similar Number of Beds, Admissions, or Outpatient Visits is a comparability factor included in the comparability data used by your hospital.) /F 4 /H /T /P 8322 0 R /T (IIIcb6iYes) /StructParent 3678 /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Type /Annot 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