This government document is issued by Developmental Services, Department of for use in Connecticut
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https://portal.ct.gov/dds/-/media/dds/dds_manual/ih/hs_17-1_attachment_a_aquatic_activity_screening_form.docx?rev=47c5a8899a5b4dae8c86d5f9eec27996&hash=218D8DA7A788C1FC81589EC4F7908B09