THE NEW HOPE FOUNDATION, INC.

(URURKA RAJADA CUSUB)

DOCUMENTATION OF ORIENTATION

Diiwaan gelinta Warbixinta

Waxaan ka mahad naqayaa in warkan soosocda la ila fiir fiiriyey si aan u fahmo. Tilmaan inaad raacsantahay adigoo xarfaha magacaaga ugu horeeya ku saxeexaya.

_____________________ Adeegyada ay bixiyaan URURKA RAJADA CUSUB

_____________________ Saacadaha adeegga/jadwalka barnaamijka

_____________________ Xuquuqda iyo waxa la filan karayo

_____________________ Sharciyada xil qarinta

_____________________ Hababka loo gudbiyo cabashooyinka

Qofka macmiilka ah: ___________________________ Taariikh_________

Qofka shaqaalha ah: ___________________________ Taariikh _________

The New Hope Foundation, Inc. (Ururka Rajada Cusub)

THE NEW HOPE FOUNDATION, INC. HOSPITAL/PHYSICIAN RELEASE FORM

Isbitaalka URURKA RAJADA CUSUB/ Warqadda sii deynta ee Dhakhtarka

Magac:__________________________________________ Maalinta dhalashada _______________

Ciwaan______________________________________________________________________________

Magaalo _______________________________ gobol______ zip-__________ Tel:________________

Dhakhtarka ______________________________ rugta caafimaadka ____________________________

Ciwaanka Dhakhatarka_________________________________________________________________

Saxeexaygan hoos ku qoran, waxan ku ogalaanyaa in la siiyo URURKA RAJADA CUSUB wararka hoos ku qoran

1. Akhbaarta sheybaarka ee cadeyneysa HIV/AIDS
2. Cadeynta dhakhtarka HIV/AIDS sheegeysa

Warsiintan waxay ujeeddadeedu tahay kaliya in la caddeeyo in la igu sheegay HIV/AIDS iyadoo waafaqeysa nidaamka hay’ adda [HRSA]. Wararka oo dhan waa la xil qariyaa , waxaan fahansanahay in feylkeygu uu ku beegmi karo xisaabi xilmaleh isaga oo waafaqsan nidaamyada xil qarinta waxaan kale oo fahansanahay inaan ka bixikaro ogalaanshahan markasta marka laga reebo inta ay horey u sacotey howshu.

Saxeexa ___________________________________ Taariikh _________________________

Saxeexa ____________________________________Taariikh _________________________

MEDICAL VERIFICTION OF HIV RELATED ILLNESS

Cilmi Ku Xaqiijinta Jirrooyinka la xiriira HIV-ga

Waxaan cadeynayaa in, ________________________ laygu arkey jirada HIV-ga iyada oo la tix raacayo Sharraxaadda Xarumaha Jira ee Xakamaynta iyo Kahortagga Cudurada la xiriira HIV-ga ama AIDS-ka.

Waxa hadda lagu arkay: HIV + Asymptomatic ____ HIV+ Symptomatic___ AIDS____

Maalinta lagu arkey _______________________________

Qodabada qeexaya aragtida cudurka_________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________ _______________________

Saxeexa Dhakhtarka Qor magaca dhakhterka

Taariikhda ______________________________

Fadlan ku lifaaq natiijada sheybaarka ee ku shaqeeya aragtida kuna celi warqadda iyo waxa ku lifaaqan ciwaankan:

THE NEW HOPE FOUNDATION, INC.

629 Woodland Street

Nashville, TN 37206

Warkani waa sir culus ee haku dirin fax

The New Hope Foundation, Inc. (Ururka Rajada Cusub)

THE NEW HOPE FOUNDATION, INC.

(URURKA RAJADA CUSUB)

CONSENT FOR THE RELEASE FOR CONFIDENTIAL INFORMATION

(Raalli ku noqosho in lagudbiyo wararkaaga sirta culis ah)

Anigoo ah, _______________________ waxan u ogalaadey

Magaca Qofka

______________________________________________in ay siiso

(qoflka ama hey’ada warbixineysa)

warkan ____________________________________________ warkan

(Qofka amaHay’adda Warka Helaysa)

soo socda_____________________________________________________________ ayadoo ujeedadu

tahay__________________________________________________

Aniga/annaga oo hoos ku saxeexan waxaan fahansannahay inaan ka bixi karo raali ka ahaanshaha markasta oo aan doono marka laga reebo in ay gaartey howsha lagu dul dhisay ku rali ahaansho noqoshadayda hore. Raalli noqoshadu waxay dhaceysaa marka ay dhamaanto mudada dhaxe ama 60 casho haddii aan si kale halkan loogu xusin

Qolada Warka Heleysa

Warkan waxaa la idiinka soo daayey diwaano si adag u xil qarskan waxaana dhowra sharciyada dowladda dhexe (federal law) marka latixraaco sharciga fadaraaliga iyo kuwa kale laguuma ogala inaad u gudbiso warkan cid kale adiga oo aan qoraal cad ka wadan cida warku ku saabsan yahay. Tani waxay u badan tahay war gud bin GAAR AH oo oo ka timaadda qofkaas

Qofka_______________________________ Taariikh _________

Saxeexa bukaanka ama qofka ka masuulka ah___________________ Taariikh_______

Saxeexa qofka goobjooga ah___________________________ Taariikh__________

The New Hope Foundation (Ururka Rajada Cusub)

THE NEW HOPE FOUNDATION, INC.

(URURKA RAJADA CUSUB)

CONSENT FOR TREATMENT

(Raalli Ku noqosho Daaweyn)

Magaca qofka ____________________________________________________

Lambarka qofka _____________________________________________

Aniga oo ah, ________________________________ waxan ka mahad naqayaa in la ii sharxay faa’iidooyinka latalinta. Waxan halkan ku bixinayaa raalli ka noqoshadayda in aan ku biiro daawaynta. Waxan fahansanahay in ay ku jiri karto, iyada oo ay weheliyaan kuwo kale, dhacdooyinkan soo socda:

*Qiimayn Lafahmo *Lataalin Qof

*Latalin Qoys *Koox Taageerayaal ah

*Kala Talin Daroogo iyo Aalkolo *Koox Jirka Dawaysa

*Ku talin Hab-Nafaqo Qaadasho *Qorshaynta Daawaynta

*Gudbin Adeeg Bulshonim *Dabagal Lasocod ah

Waxaa la I siiyey warar ku saabsan daryeello kale oo ay bulshadu heli karto si la iiga caawiyo baahidayda. Waxan ka mahad naqayaa in la I siiyey fursad ah in aan diidi karo ama aan yeeli karo in xarunto la igu daweeyo xarunta. Waxaan si xor ah u doortay in aan ka qaybqaato.

Macmiilka Saxeexiisa _________________________________ Taariikh ____________

Waalid/Mas’uul Sharci ________________________________ Taariikh ____________

Shaqaalaha Rugta ____________________________________ Taariikh ____________

The New Hope Foundation (Ururka Rajada Cusub)