Download:
pdf |
pdfOMB Approved No. 2900-0776
Respondent Burden: 30 minutes
SHOULDER AND ARM CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
ON REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD A SHOULDER AND/OR ARM CONDITION?
IF YES, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS:
NO
YES
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
RIGHT
RIGHT
RIGHT
LEFT
LEFT
LEFT
BOTH
BOTH
BOTH
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SHOULDER AND/OR ARM CONDITION (brief summary)
2B. DOMINANT HAND:
RIGHT
LEFT
AMBIDEXTROUS
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE SHOULDER AND/OR ARM?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
4. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, DOCUMENT THE
POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL
MEASUREMENTS BELOW.
FOLLOWING THE INITIAL ASSESSMENT OF ROM, PERFORM REPETITIVE USE TESTING. FOR VA PURPOSES, REPETITIVE USE TESTING MUST BE INCLUDED
IN ALL JOINT EXAMS. THE VA HAS DETERMINED THAT 3 REPETITIONS OF ROM (at a minimum) CAN SERVE AS A REPRESENTATIVE TEST OF THE EFFECT OF
REPETITIVE USE. AFTER THE INITIAL MEASUREMENT, REASSESS ROM AFTER 3 REPETITIONS. REPORT POST-TEST MEASUREMENTS IN SECTION 5.
A. RIGHT SHOULDER FLEXION
Select where flexion ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
VA FORM
JAN 2011
21-0960M-12
Page 1
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
B. RIGHT SHOULDER ABDUCTION
Select where abduction ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
C LEFT SHOULDER FLEXION
Select where flexion ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
D. LEFT SHOULDER ABDUCTION
Select where abduction ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than a
shoulder or arm condition, such as age, body habitus, neurologic disease), EXPLAIN:
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. IS THE VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES
NO
IF UNABLE, PROVIDE REASON:
IF VETERAN IS UNABLE TO PERFORM REPETITIVE-USE TESTING, SKIP TO SECTION 6.
IF VETERAN IS ABLE TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS.
5B. RIGHT SHOULDER POST-TEST ROM
Select where flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where abduction ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
VA FORM 21-0960M-12, JAN 2011
Page 2
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING (Continued)
5C. LEFT SHOULDER POST-TEST ROM
Select where flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where abduction ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
6. THE FOLLOWING SECTION ADDRESSES REASONS FOR FUNCTIONAL LOSS, IF PRESENT, AND ADDITIONAL LOSS OF ROM AFTER REPETITIVE-USE TESTING,
IF PRESENT. THE VA DEFINES FUNCTIONAL LOSS AS THE INABILITY TO PERFORM NORMAL WORKING MOVEMENTS OF THE BODY WITH NORMAL
EXCURSION, STRENGTH, SPEED, COORDINATION AND/OR ENDURANCE.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE SHOULDER AND ARM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE SHOULDER AND ARM?
YES
NO
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE SHOULDER AND ARM AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (check all that apply and indicate side affected):
NO FUNCTIONAL LOSS FOR RIGHT UPPER EXTREMITY
NO FUNCTIONAL LOSS FOR LEFT UPPER EXTREMITY
LESS MOVEMENT THAN NORMAL
Right
Left
Both
MORE MOVEMENT THAN NORMAL
Right
Left
Both
WEAKENED MOVEMENT
Right
Left
Both
EXCESS FATIGABILITY
Right
Left
Both
INCOORDINATION, IMPAIRED ABILITY
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY
Right
Left
Both
PAIN ON MOVEMENT
Right
Left
Both
SWELLING
Right
Left
Both
DEFORMITY
Right
Left
Both
ATROPHY OF DISUSE
Right
Left
Both
SECTION VII - PAIN (pain on palpation)
7A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS/SOFT TISSUE/BICEPS TENDON OF EITHER SHOULDER?
YES
NO
IF YES, SHOULDER AFFECTED:
Right
Left
Both
Left
Both
7B. DOES THE VETERAN HAVE GUARDING OF EITHER SHOULDER?
YES
NO
IF YES, SHOULDER AFFECTED:
Right
SECTION VIII - MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 NO MUSCLE MOVEMENT
1/5 PALPABLE OR VISIBLE MUSCLE CONTRACTION, BUT NO JOINT MOVEMENT
2/5 ACTIVE MOVEMENT WITH GRAVITY ELIMINATED
3/5 ACTIVE MOVEMENT AGAINST GRAVITY
4/5 ACTIVE MOVEMENT AGAINST SOME RESISTANCE
5/5 NORMAL STRENGTH
SHOULDER ABDUCTION
SHOULDER FORWARD FLEXION:
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
SECTION IX - ANKYLOSIS
9. DOES THE VETERAN HAVE ANKYLOSIS OF THE GLENOHUMERAL ARTICULATION (SHOULDER JOINT)?
YES
NO
IF YES, INDICATE SEVERITY AND SIDE AFFECTED:
ABDUCTION TO 60 DEGREES; CAN REACH MOUTH AND HEAD
Right
Left
Both
ABDUCTION LIMITED TO BETWEEN 60 AND 25 DEGREES
Right
Left
Both
ABDUCTION LIMITED TO 25 DEGREES FROM THE SIDE
Right
Left
Both
VA FORM 21-0960M-12, JAN 2011
Page 3
SECTION X - SPECIFIC TESTS FOR ROTATOR CUFF CONDITIONS
10A. HAWKINS' IMPINGEMENT TEST (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
indicates a positive test; may signify rotator cuff tendinopathy or tear)
NEGATIVE
POSITIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
N/A
Left
Right
Both
10B. EMPTY-CAN TEST (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner.
Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear)
NEGATIVE
POSITIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
N/A
Left
Right
Both
10C. EXTERNAL ROTATION/INFRASPINATUS STRENGTH TEST (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against
resistance.. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear)
NEGATIVE
POSITIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
N/A
Left
Right
Both
10D. LIFT-OFF SUBSCAPULARIS TEST (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may
indicate subscapularis tendinopathy or tear)
NEGATIVE
POSITIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
N/A
Left
Right
Both
SECTION XI - HISTORY AND SPECIFIC TESTS FOR INSTABILITY/DISLOCATION/LABRAL PATHOLOGY
11A. IS THERE A HISTORY OF MECHANICAL SYMPTOMS (clicking, catching, etc.)?
NO
YES
IF YES, SIDE AFFECTED:
Left
Right
Both
11B. IS THERE A HISTORY OF RECURRENT DISLOCATION (subluxation) OF THE GLENOHUMERAL (scapulohumeral) JOINT?
YES
NO
IF YES, INDICATE FREQUENCY, SEVERITY AND SIDE AFFECTED (check all that apply):
INFREQUENT EPISODES
Right
Left
Both
FREQUENT EPISODES
Right
Left
Both
GUARDING OF MOVEMENT ONLY AT
SHOULDER LEVEL
Right
Left
Both
GUARDING OF ALL ARM MOVEMENTS
Right
Left
Both
11C. CRANK APPREHENSION AND RELOCATION TEST (With patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
instability with further external rotation may indicate shoulder instability)
NEGATIVE
POSITIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
Right
N/A
Left
Both
SECTION XII - HISTORY AND SPECIFIC TESTS FOR CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT
AND STERNOCLAVICULAR JOINT CONDITIONS
12A. DOES THE VETERAN HAVE AN AC JOINT CONDITION OR ANY OTHER IMPAIRMENT OF THE CLAVICLE OR SCAPULA?
YES
NO
IF YES, INDICATE SEVERITY AND SIDE AFFECTED
MALUNION OF CLAVICLE OR SCAPULA
Right
Left
Both
NONUNION OF CLAVICLE OR SCAPULA
WITHOUT LOOSE MOVEMENT
Right
Left
Both
NONUNION OF CLAVICLE OR SCAPULA
WITH LOOSE MOVEMENT
Right
Left
Both
DISLOCATION (ACROMIOCLAVICULAR SEPARATION
OR STERNOCLAVICULAR DISLOCATION)
Right
Left
Both
OTHER (Describe)
Right
Left
Both
12B. IS THERE TENDERNESS ON PALPATION OF THE AC JOINT?
YES
NO
IF YES, INDICATE SIDE:
Right
Left
Both
12C. CROSS-BODY ADDUCTION TEST (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint
pathology)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
IF POSITIVE, SIDE AFFECTED:
VA FORM 21-0960M-12, JAN 2011
Right
N/A
Left
Both
Page 4
SECTION XIII - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
13A. HAS THE VETERAN HAD A TOTAL SHOULDER JOINT REPLACEMENT?
NO
YES
IF YES, INDICATE SIDE AND SEVERITY OF RESIDUALS
RIGHT SHOULDER
DATE OF SURGERY:
RESIDUALS:
NONE
INTERMEDIATE DEGREES OF RESIDUAL WEAKNESS, PAIN AND/OR LIMITATION OF MOTION
CHRONIC RESIDUALS CONSISTING OF SEVERE PAINFUL MOTION AND/OR WEAKNESS
OTHER (Describe)
LEFT SHOULDER
DATE OF SURGERY:
RESIDUALS:
NONE
INTERMEDIATE DEGREES OF RESIDUAL WEAKNESS, PAIN AND/OR LIMITATION OF MOTION
CHRONIC RESIDUALS CONSISTING OF SEVERE PAINFUL MOTION AND/OR WEAKNESS
OTHER (Describe)
13B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
NO
YES
IF YES, INDICATE SIDE AFFECTED:
Right
Left
Both
DATE AND TPYE OF SURGERY:
13C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
NO
YES
IF YES, INDICATE SIDE AFFECTED:
Right
Left
Both
IF YES, DESCRIBE RESIDUALS:
SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
14A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
DIAGNOSIS SECTION 1?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN 39 SQUARE cm (6 square inches)?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN DIAGNOSIS SECTION 1?
YES
NO
IF YES, DESCRIBE (Brief summary):
SECTION XV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
15. DUE TO THE VETERAN'S SHOULDER AND/OR ARM CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE
FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper
extremity include grasping, manipulation, etc)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLLY SERVE THE VETERAN.
NO
IF YES, INDICATE EXTREMITY(IES) (check all extremities for which this applies):
Right upper
Left upper
FOR EACH CHECKED EXTREMITY, DESCRIBE LOSS OF EFFECTIVE FUNCTION, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, AND PROVIDE
SPECIFIC EXAMPLES (brief summary):
VA FORM 21-0960M-12, JAN 2011
Page 5
SECTION XVI - DIAGNOSTIC TESTING
NOTE: The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by imaging studies. Once such arthritis has been documented, no
further imaging studies are required by VA, even if arthritis has worsened.
16A. HAVE IMAGING STUDIES OF THE SHOULDER BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES
NO
IF YES, INDICATE SHOULDER:
Right
Left
Both
16B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (Brief summary):
SECTION XVII - FUNCTIONAL IMPACT AND REMARKS
17. DOES THE VETERAN'S SHOULDER CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S SHOULDER CONDITIONS PROVIDING ONE OR MORE EXAMPLES:
SECTION XVIII - FUNCTIONAL IMPACT AND REMARKS
18. REMARKS (If any)
SECTION XIX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
19A. PHYSICIAN'S SIGNATURE
19D. PHYSICIAN'S PHONE AND FAX
NUMBER
19B. PHYSICIAN'S PRINTED NAME
19E. PHYSICIAN'S MEDICAL LICENSE NUMBER
19C. DATE SIGNED
19F. PHYSICIAN'S ADDRESS
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
IMPORTANT - Physician please fax the completed form to
(VA Regional Office FAX No.)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal
Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in
which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA
system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is
required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN
account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the
disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum
benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will
need an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is
displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-0960M-12, JAN 2011
Page 6
| File Type | application/pdf |
| File Title | VA Form 21-0960M-12 |
| Subject | Shoulder and Arm Conditions - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-12-23 |
| File Created | 2011-12-22 |