source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZP61.m@ 1722

Last change on this file since 1722 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version
File size: 4.6 KB
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1EASEZP61 ;ALB/AMA - Print 1010EZ, Version 6 or greater, Cont. ; 10/19/2000
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**51,60**;Mar 15, 2001
3 ;
4 ; This routine copied from EASEZPF1; if the version # of the 1010EZ
5 ; application is 6.0 or greater, then this routine will be executed.
6 ;
7EN(EALNE,EAINFO) ;Entry point for VA 10-10EZ, Version 6 or greater, page 1
8 ; Called from EN^EASEZP6F
9 N X,EASD
10 ;
11 S EASD=$NA(^TMP("EASEZ",$J,1))
12 D HDRMAIN^EASEZP6F(.EALNE)
13 D DEM
14 ;
15 D FT^EASEZP6F(.EALNE,.EAINFO)
16 S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
17 Q
18 ;
19DEM ; Print VA 10-10 Section I, Demographic information
20 ;
21 W !!?50,"SECTION I - GENERAL INFORMATION"
22 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
23 W !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
24 W !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
25 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
26 ;
27 W !,"1. VETERAN'S NAME (Last, First, Middle Name)",?50,"|2. OTHER NAMES USED",?87,"|3. MOTHER'S MAIDEN NAME"
28 W !?3,@EASD@(2),?50,"| ",@EASD@(3),?87,"| ",@EASD@("3A")
29 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
30 ;
31 W !,"4. GENDER",?16,"|5. WHAT IS YOUR RACE? ",@EASD@("4B"),"AMERICAN INDIAN OR ALASKA NATIVE"
32 W ?90,@EASD@("4E"),"ASIAN",?103,@EASD@("4C"),"BLACK OR AFRICAN AMERICAN"
33 W !?3,@EASD@(4),?16,"|",?41,@EASD@("4D"),"NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER"
34 W ?90,@EASD@("4F"),"WHITE",?103,@EASD@("4G"),"UNKNOWN BY PATIENT"
35 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
36 ;
37 W !,"6. ARE YOU SPANISH, HISPANIC,",?33,"|7. SOCIAL SECURITY NUMBER",?62,"|9. DATE OF BIRTH (mm/dd/yyyy)",?95,"|10. RELIGION"
38 W !?3,"OR LATINO? ",@EASD@("4A"),?33,"| ",@EASD@(5),?62,"| ",@EASD@(7),?95,"| ",@EASD@(8)
39 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
40 ;
41 W !,"8. CLAIM NUMBER",?66,"|9A. PLACE OF BIRTH (City & State)"
42 W !?3,@EASD@(6),?66,"| ",@EASD@("8A")
43 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
44 ;
45 W !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. STATE",?107,"|11C. ZIP CODE (9 digits)"
46 W !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9C"),?107,"| ",@EASD@("9D")
47 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
48 ;
49 W !,"11D. COUNTY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
50 W !?5,@EASD@("9E"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
51 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
52 ;
53 W !,"11G. CELLULAR TELEPHONE NUMBER (Include area code)",?66,"|11H. PAGER NUMBER (Include area code)"
54 W !?5,@EASD@("11G"),?66,"| ",@EASD@("11H")
55 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
56 ;
57 W !,"12. TYPE OF BENEFIT(S) APPLIED FOR:"
58 W !?4,@EASD@("1A")
59 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
60 ;
61 W !,"13. IF APPLYING FOR HEALTH SERVICES OR ENROLLMENT, WHICH VA MEDICAL CENTER",?77,"|14. HAVE YOU BEEN SEEN AT A VA HEALTH CARE FACILITY?"
62 W !?4,"OR OUTPATIENT CLINIC DO YOU PREFER? ",@EASD@("1B"),?77,"| ",@EASD@("11C") I @EASD@("11C")="YES" W ", LOCATION: ",@EASD@("11D")
63 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
64 ;
65 W !,"15. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE BECOMES",?87,"|16. CURRENT MARITAL STATUS"
66 W !?4,"AVAILABLE? ",@EASD@("11B") I @EASD@("11B")="NO" W ", I am only enrolling in case I need care in the future."
67 W ?87,"| ",@EASD@(12)
68 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
69 ;
70 W !,"17. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|17A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
71 W !?4,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
72 W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
73 W $E(EALNE("UL"),1,48)
74 W !?4,$P(@EASD@("19A"),U,2),?83,"|17B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
75 W !?4,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
76 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
77 ;
78 W !,"18. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|18A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
79 W !?4,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
80 W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
81 W $E(EALNE("UL"),1,48)
82 W !?4,$P(@EASD@("20A"),U,2),?83,"|18B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
83 W !?4,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
84 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
85 ;
86 W !,"19. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE"
87 W !?4,"THE TIME OF DEATH (NOTE: THIS DOES NOT CONSTITUTE A WILL OR TRANSFER OF TITLE): ",@EASD@(21)
88 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
89 Q
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