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| ==Data Request Form== | | ==Data Request Form== |
| {| class="wikitable" border=1 <hiddentext> set to 0 for no borders</hiddentext>
| | * bitmap copy of form?? |
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| |style="font-size:11pt" width="48" height="14" |
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| |style="font-size:8pt;font-weight:bold;font-style:Italic;text-decoration:underline" |
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| |style="font-size:11pt" |
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| |style="font-size:6pt" height="14" | Revised on 5 May 2008
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| |style="font-size:8pt;font-weight:bold;text-decoration:underline;color:#FF0000" | ATTENTION:
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| | Julie Mojica, Statistician (Phone 787-1690)
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| |style="font-size:11pt;text-decoration:none" |
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| |- valign="bottom"
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| |style="font-size:11pt" height="14" |
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| |style="font-size:11pt" |
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| |style="font-size:6pt;font-weight:bold;text-decoration:underline" |
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| | Trish Ostryzniuk, Regional Manager (Phone 787-3055)
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| |style="font-size:11pt;text-decoration:none" |
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| |style="font-size:11pt" height="14" |
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| |style="font-size:8pt;text-decoration:underline" | Fax: 787-2823
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| |style="font-size:11pt" |
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" |
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" |
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| |style="font-weight:bold" | Critical Care Database Information Request Form
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" | Date of Request:
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| | Date Information required by:
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| |style="font-size:11pt" height="14" |
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| |style="font-size:8pt;font-style:Italic" | (Allow at least 2 weeks for completion of request)
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| |style="font-size:11pt" |
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| | height="14" | Submitted by:
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| | Department:
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" |
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" | Who is the request for?
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| | Department:
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| |- valign="bottom"
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| |style="font-size:11pt" height="14" |
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| |style="font-size:11pt" |
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| |style="font-size:7pt" | (if different from above)
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" |
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" | List all others who will have access to this data:
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| |- style="font-size:11pt" valign="bottom"
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| | height="14" |
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| | height="14" |
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| |- valign="bottom"
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| |style="font-size:12pt;text-decoration:underline" height="16" | Intended use of data :
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| |style="font-size:11pt;text-decoration:none" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:12pt;text-decoration:underline" | Specific Data Requested?
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| |style="font-size:12pt;text-decoration:none" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |- valign="bottom"
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| |style="font-size:8pt;font-style:Italic" height="14" | Check the item and elaborate further in the space below.
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| | Time Period:
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| |style="font-size:8pt" | Start
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:8pt" | End
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" height="14" |
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| | Research Project - Please attached the following:
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:6pt" | ( mm/dd/yyyy)
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| |style="font-size:6pt" |
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| |style="font-size:6pt" |
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| |style="font-size:6pt" |
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| |style="font-size:6pt" |
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| |style="font-size:6pt" | (mm/dd/yyyy)
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| |style="font-size:6pt" |
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| |style="font-size:6pt" |
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| |style="font-size:11pt" |
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| |- valign="bottom"
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| |style="font-size:11pt" height="14" |
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| |style="font-size:8pt;font-style:Italic" | 1.Copy of Research Ethics Boards' Approval Form
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" | Hospital & Unit:
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:8pt" | All
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| |style="font-size:11pt" |
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| |style="font-size:8pt" |
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| |style="font-size:11pt" |
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| |- valign="bottom"
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| |style="font-size:11pt" height="14" |
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| |style="font-size:8pt;font-style:Italic" | 2.Copy of Research Proposal/Protocol Summary
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:9pt" | HSC:
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | MICU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | CCU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | SICU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | IICU
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| |style="font-size:11pt" |
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| |style="font-size:11pt" height="14" |
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| | Teaching
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| | Resource Utilization
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| |style="font-size:11pt" |
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| |style="font-size:8pt" |
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| |style="font-size:9pt" | STB:
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| |style="font-size:11pt" |
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| |style="font-size:8pt" | MICU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | CCU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | SICU
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | CICU
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| |style="font-size:11pt" |
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| |style="font-size:11pt" height="14" |
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| | Audit/Evaluation/Review
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| | Others - Please specify.
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:9pt" | CON
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| |style="font-size:11pt" |
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| |style="font-size:9pt" | GRA
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| |style="font-size:8pt" |
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| |style="font-size:9pt" | OAK
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| |style="font-size:8pt" |
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| |style="font-size:9pt" | VIC
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| |style="font-size:11pt" |
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| | height="14" |
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| |style="font-size:11pt" height="14" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:11pt" | Type of Report:
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| |style="font-size:11pt" |
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| |style="font-size:11pt" |
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| |style="font-size:8pt" | Combined Report
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| |style="font-size:8pt" |
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| |style="font-size:8pt" |
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| |style="font-size:8pt" |
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| |style="font-size:8pt" | Individual Reports
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| |style="font-size:11pt" |
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| | height="14" |
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| |- valign="bottom"
| |
| |style="font-size:11pt" height="14" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| | Summary statistics required?
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:9pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:8pt" | YES
| |
| |style="font-size:11pt" |
| |
| |style="font-size:8pt" | NO
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| | |
| |- valign="bottom"
| |
| |style="font-size:11pt" height="14" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| | (Include N , Mean, Standard Deviation, Sum, Minimum, Maximum)
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:9pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:8pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:8pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| | |
| |- valign="bottom"
| |
| |style="font-size:11pt" height="14" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:8pt;font-style:Italic" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| |style="font-size:11pt" |
| |
| | |
| ==Database Status==
| |
| * Intermittently updated..........
| |
| | |
| {| class="wikitable" border=1 <hiddentext> set to 0 for no borders</hiddentext>
| |
| |- style="font-size:11pt" valign="bottom"
| |
| | width="64" height="20" | Database
| |
| | width="67" | Total Records
| |
| | width="76" | to date Aug 6.08
| |
| | |
| |- valign="bottom"
| |
| |style="font-weight:bold" height="14" | Critical Care
| |
| |style="font-size:11pt" | 64,876
| |
| |style="font-size:11pt" |
| |
| | |
| |- valign="bottom"
| |
| |style="font-weight:bold" height="14" | Medicine
| |
| |style="font-size:11pt" | 44,106
| |
| |style="font-size:11pt" |
| |
| | |
| |}
| |
|
| |
|
| [[User:TOstryzniuk|TOstryzniuk]] 13:47, 6 August 2008 (CDT) | | [[User:TOstryzniuk|TOstryzniuk]] 13:47, 6 August 2008 (CDT) |