Reference form
 
 
 
 
 
 
 
 
 
 
 
Yes
No
Sometimes
 
Yes
No
 
 
 
Yes
No
 
 
Yes (please provide more details in the box below)
No
 
 
Yes
No
 
 
Yes
No (please provide more details in the box below)
 
 
Yes
No
 
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