But is ADHD medications really worth it? The information provided on this website should not serve as a substitute for professional medical care. The urine test is just a kidney screen to test for sugar and protein. Some of the common ADHD drugs approved by the FDA authorities include: These new approvals could include aducanumab for Alzheimer disease, pegcetacoplan for the rare disease PNH, and 3 drugs for patients with moderate-to-severe atopic dermatitis: Check our, Scientists Identify Nutrient That Cancer Cells Crave, Addiction Expert Weighs In on Ben Affleck Relapse Speculation, Trigger for Worlds Most Common Liver Disease Identified, 1 in 8 Infants Born in West Virginia Between 2020 and 2022 Has Been Exposed to Drugs, Here Are the Lasting Effects of Childhood Trauma on Mental Health, Blood Tests and Mental Illness: The Latest Research, New Study Confirms Pancreatic Cancer Rates Rising Faster in Women Than Men, Social Prescriptions Could Become the Next Big Thing in Healthcare, Trauma and PTSD Can Have Devastating Effects on an Individual, Study Suggests Alcohol Consumption Linked to Acceleration of Alzheimers Disease, Frontotemporal Dementia: Symptoms, Causes, Diagnosis, and Treatment. informed clinical guidelines and expert opinion, where evidence is lacking, and are generally reflective of FDA approved indications and recommendations. Shares of KemPharm skyrocketed as much as 90% on Wednesday after the FDA approved the company's once-daily treatment for ADHD called Azstarys. Whats happening The FDA approved Azstarys (formerly KP415), a new 1. is the pain and any restrictions that come with it. 0000109962 00000 n Its done to determine that there is no early onset of conditions like high blood pressure breaking down the kidneys, or early signs of diabetes, or kidney infection WebADD medication, Painkillers, Anti-inflammatories, Anti-diarrhea medication, and. My dot physician lost my specimen who can I talk to about this they say they have to report it to MRO what does this mean for me? GR: Gender Restriction . In practice, ADD/HD is typically diagnosed and treated in the primary care setting. Then it falls to the CME for his final decision. So how did you get it as an adult? 4 Years Like other SNRIs used to treat depression, Qelbree and Strattera carry black-box warnings about an increase in suicidality in the first months of treatment, particularly among teenaged patients. At US Compliance Services, were dedicated to helping trucking businesses navigate the often confusing legal landscape of DOT and FMCSA regulations. Ifthe medical examiner believes that the blood in the urine may indicate a condition that affects the ability of the commercial driver to safely, the driver may be referred to a primary care physician or specialist for further evaluation. 0000104312 00000 n Numerous co-morbid psychiatric conditions are associated with ADD/HD. Pseudoephedrine, commonly found in the cold and flu medication Sudafed, is banned on the day of competition. Kapvay; Catapres (clonidine ER) Intuniv; Tenex (guanfacine ER) Atomoxetine is the oldest non-stimulant medication specifically approved for ADHD. Visit this page again soon to see our response. Not sure if that changes the answer or not. The medications it self. fayette county school calendar 2020 21; james murphy lcd soundsystem net worth However, doses higher than clinically recommended may produce insomnia and hyper-focusing. All of these things are to help the medical examiner determine whether you are medically fit to operate a CMV safely. Attention-deficit/hyperactivity disorder. I have never had a low or high blood sugar blackout. Im on light duty, not medically cleared to work, dropped from driving by company I WAS STILL TOLD TO DO DOT DRUG TEST how is this possible. Qelbree (viloxazine), approved by the FDA on April 2, 2021, is a non- stimulant medication used to treat ADHD in children between the ages of 6 and 17. If you are a neurobiologist, you might say ADD/HD is caused by aberrant dopamine receptors in the brain due to an inherited genetic abnormality. As you can see, some of these issues can be unsafe for you and the public. Extremities and Trunk Updated October 2022. ADHD symptoms can lead to misunderstandings and frustrations. The MRO will interview the driver to determine if there is an alternative medical explanation for the drugs found in the urine specimen. My medical card expires in a month. One of the best ways for a driver to answer a question about whether a medication may be a disqualifier or not, is to read about the side effects of that medication. Terms | If you have any questions as to whether a specific pharmaceutical may 0 FDA Approves Azstarys, a Once-Daily Stimulant for ADHD Written by Amy B. Gragnolati, PharmD, BCPS Published on March 31, 2021 Key takeaways: Azstarys was recently approved by the FDA to treat ADHD in people ages 6 years and older. Men Just make sure you inform the medical examiner about your condition and the medications you are taking for it. They usually have side-effects that cause drowsiness and that is the main problem. For a class A cdl interstate driver, DOT/FMCSA has you as a high risk and disqualifies these medications for long haul drivers. @ Mike When it comes to Attentional Disorders, some Neuroimaging Specialists target the frontal and prefrontal cortices, while others claim the cause of ADD/HD is in the thalamus or basal ganglia. Each state has its own rules. 5. The following is a list of many brand and generic names of stimulants used for treating ADHD in children and adults: Adderall (amphetamine/ dextroamphetamine) Adderall XR (amphetamine/ Im a CDL driver. Each company we work with has specific experience requirements for their drivers. A behaviorist might say that ADD/HD is learned due to environmental conditioning in a susceptible individual. Since antidepressants arent approved to formally treat ADHD, this would be considered off-label use. 0000101406 00000 n 0000000996 00000 n Email: ODAPCWebMail@dot.gov Phone: 202-366-3784 Alt Phone: 800-225-3784 Fax: 202-366-3897 If you are deaf, hard of hearing, or have a speech disability, please dial 7-1-1 to access telecommunications relay services. Can I get a medical certificate if Im being treated for a medical condition by my doctor? So if youre looking for professional help, dont delay or ignore it because of what youve read here. It will limit your DOT medical certificate to one year at a time. , Positive Top-Line Results Reported for Fed/Fast Study of Novel ADHD Treatment, Treating ADHD in Children: Concerns, Controversies, Safety Measures, From the Pages of Psychiatric Times: December 2022, Expert Perspectives on the Unmet Needs in the Management of Major Depressive Disorder, Novel Delivery Systems Utilized in the Treatment of Adult ADHD, Expert Perspectives on the Clinical Management of Bipolar 1 Disorder, Tales From the Clinic: The Art of Psychiatry, Pharmacological Management of Treatment-Resistant Anorexia Nervosa, Reducing Heterogeneity in NonTreatment-Resistant and Treatment-Resistant Schizophrenia, Treatment-Resistant OCD: Strategies and Novel Treatment Options, The Current State of the Art and the Not Too Distant Future, Mania With Psychosis vs Schizophrenia vs Schizoaffective Disorder, Bipolar Type, 5 Crypto Investing Rules for Busy Doctors, Doorknob Moments: Why They Happen and How to Use Them, Chatbots for Child Mental Health Care: Helpful, but Limited, Lyme Disease in Psychiatry: Controversies, Chronic Symptoms, and Recent Developments, | Novel Delivery Systems Utilized in the Treatment of Adult ADHD, | Expert Perspectives on the Clinical Management of Bipolar 1 Disorder, Effect of delayed-release and extended-release methylphenidate on caregiver strain and validation of psychometric properties of the Caregiver Strain Questionnaire: results from a phase 3 trial in children with attention-deficit/hyperactivity disorder, Model-based approach for establishing the predicted clinical response of a delayed-release and extended-release methylphenidate for the treatment of attention-deficit/hyperactivity disorder, https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2021.6.12. Any anti-seizure medication used for the prevention of seizures is disqualifying. CDL Grad, No Experience Attentional disorders can be caused by environmental toxins in the case of lead and cadmium, brain injury, inheritance, or behavioral modeling. The 391.41 CMV Driver Medication Form, MCSA-5895, requests additional information regarding medications prescribed by the treating physician as an optional What medications disqualify a CMV driver? 80% lower and upper set; farm accident westhope, nd; scales of justice oxford january If you live with ADHD, understanding the connection between your condition and dopamine may help you better figure out how your brain works and what treatments might be right for you. 27. Especially in the beginning, it will be helpful to have someone knowledgeable to ask questions, monitor changes to your symptoms, and discuss potential side effects. Written by Freddy S. Starr, M.D., FAACAP, QEEG. 3 Like atomoxetine People often use medication to help them manage their ADHD symptoms, like impulsivity or trouble focusing. Both the FMCSA and the current research appear to agree on the necessity to identify individuals with ADD/HD and ensure their management is adequate. have been proven to reduce the symptoms of inactivity, hyperactivity, and impulsivity in adults and children with ADHD. J Am Acad Child Adolesc Psychiatry. Webdot approved adhd medications 2021one vote less political cartoon. There are no OTC ( over-the-counter) stimulants approved for treating ADHD. I see the state and the feds both are represented by associations like MADD but the 10 company profit motivated tools like association of car insurance companies and health care insurance company and the governor for safely association and uber to. cathlino 124 wide reversible modular sofa chaise with What anti-anxiety medication in okay to take and still be safe to drive? Treatments like EEG-Biofeedback (Neurofeedback) may allow for permanent attention retraining with reduction of symptoms in individuals with ADD/HD. A CMV driver cannot be qualified if on Methadone. Can I still drive CMV? The goal is to get possible low doses that will effectively reduce symptoms. Medications Once youve completed the program, youll need to undergo a return-to-duty drug test while under observation. Anti-seizure medication is also disqualifying, if it is used to treat seizures. It will cause any medical examiner to question your reaction to this medication. Specific care should be taken when assessing a potential commercial motor vehicle driver for this disorder, as other disorders may overlay proper diagnosis and treatment. Required fields are marked *. WebThe U.S. Food & Drug Administration (FDA) is responsible for pharmaceutical admissibility determinations. Gomeni R, Komolova M, Incledon B, Faraone SV. Care should be taken when prescribing psychostimulants due to their abuse potential and potential for addiction. Some types of stimulants for ADHD treatment includes: Unlike stimulants, which increase brain hormones to improve concentration, non-stimulants also affect the neurological hormones but do not increase dopamine levels. When you choose to work with us, youll get proactive alerts of any compliance issues our team finds. Published: Feb. 23, 2023 at 4:00 a.m. 202 0 obj <> endobj Is this also the same with prescribed Suboxone? However, all drivers who fail drug tests must follow the same procedure to return to work. I just found a job driving school bus. Im on thinner and BP meds. 2. In other instances, it depends on the professional opinion(s) ofboth the DOT medical examinerand the prescribing doctor. Generic name: viloxazine hydrochloride. By checking this box and clicking the "Send me job offers" button below, I represent that I: By checking this box and clicking the "Send me job offers" button below. Studies show a 50% reduction in hyperactivity and All rights reserved. If your diabetes is treated with insulin, you will be disqualified for inter-state driving. 0000101718 00000 n Meds are just one tool to manage ADHD. WebSimone Biles' ADHD medication is banned in Japan, but a Tokyo 2020 exemption allowed them for athletes. 3 Years You or your traveling companion may consult the TSA officer about the best way to relieve any concerns during the screening process. You will need to provide supporting documentation from your prescribing doctors. Early in the COVID-19 pandemic, most large private insurance companies and the Centers for Medicare & Medicaid Services (CMS) waived the requirement that patients be seen in personeven when those patients are being started on Schedule II stimulants. Will the doctor know Im taking insulin when he does my tests? Either way I appreciate the response. While ADHD medications work exceptionally for children, medications still come with their risks. There is going to be two issues passing the DOT/FMCSA medical certification examination. If it is controlled, you will get a time-limited certification and most likely need to re-certify annually. United States Department of Transportation, National Registry of Certified Medical Examiners, ADA Requirements for Over-the-Road Bus Companies, Apply for a New USDOT Number and/or Authority, Pocket Guide to Large Truck and Bus Statistics, Review each medication - prescription, non-prescription and supplement, Request a letter from the prescribing doctor. If not, dont bother, unless it could interfere with your employability. Whats the link between dopamine and ADHD? If the driver has a prescription for a controlled substance, their doctor must provide the medical examiner with a written letter that clears the driver for driving. 0000005559 00000 n Federal government websites often end in .gov or .mil. Results from a randomized controlled trial published in April 2021 found that this formulation does indeed help in that respect. Further refusal to comply will likely result in dismissal from the company. Although drugs must prove both safety and efficacy, devices need only prove safety. endstream endobj 209 0 obj <>stream ", Conversely, a recent study found that stimulant medication improved safety in routine driving while reducing ADHD symptoms with minimal adverse effects, using a validated driving simulator paradigm. The only long-acting ADHD medication option on the PBS is Two Donation-Based Wellness Events to Try at Seva Experience this September, Your Mind Wanders Because Your Brain Whispers, More than 9 million adults and 6 million children aged 417 suffer from. Will Adderal disqualify me ? Before posting, please make sure you are on the appropriate Category page, so that relevant questions and answers can be found by other drivers too. 2021. Neurologic and Mental Dyanavel XR is a central nervous system stimulant prescription medicine used for the treatment of ADHD in individuals aged 6 years and older. Even in this event, the medical examiner is not obligated to follow the recommendation of the prescribing doctor. Nonstimulant Medication. 0000005518 00000 n The medical examiner will require documentation from your treating physician stating that the treatment is effective, and that no side effects are present that will impact your ability to safely operate a commercial vehicle. Prescription stimulant medications such as amphetamine, methylphenidate, and lisdexamfetamine are commonly prescribed, along with behavioral therapy, as first-line treatment for ADHD. According to the 2016 National Survey of Childrens Health (NSCH), 62% of children (ages 2 to 17) diagnosed with ADHD were Qelbree (viloxazine hydrochloride) is a serotonin norepinephrine modulating agent (SNMA) for the treatment If you decide that medications are what you need for your attention deficit hyperactive disorder, then you want to take your drugs in the right way. check that your diabetes is adequately controlled, documentation from your prescribing physician, documentation from your treating physician. WebThe WP Debugging plugin must have a wp-config.php file that is writable by the filesystem. If you decide to try medication for ADHD, consider reaching out to a healthcare professional who has experience with ADHD. Share sensitive information only on official, secure websites. WebThe ADHD Medication Guide is a visual aid for professionals caring for individuals with ADHD. Now that all dot medical examiners are federally certified it will be reported and you will not be able to pass an exam without the releaseyou should be able to You will need to be on these meds for 30 days to make sure you have no abreactions. WebSolicitar ms informacin: 310-2409701 | administracion@consultoresayc.co. A driver cannot take a controlled substance or prescription medication without a prescription from a licensed practitioner. If you have any questions or need assistance, please give us a call at 877-352-1996. There has been a great deal of work in brain imaging in the area of Attentional Disorders, since President George Bush, Sr. allocated $10.2 billion to studying the brain. Antidepressants show a 2% greater incidence of suicidality than placebo, and use of these medications has been not associated with successful suicide attempts.4 However, these medications are generally less effective than stimulants in treating ADHD. Increase by 5-10 mg increments. FRA, FMCSA, FTA, FAA, and PHMSA) and the USCG have specific drug and alcohol testing regulations that outline who is subject to their 0000001309 00000 n Trucker Docs will answer your question as soon as possible. I had to start insulin for my diabetes. In order for you to receive the best possible offers, please make sure your answers above are accurate prior to submitting. DeepWell DTx Unveils Winners for Inaugural Mental Health Game Jam, A Step by Step Guide to Marriage Counselling, Employees Still Expect Employers to Prioritise Physical Health Over Mental Well-Being, Mother's Empathy Linked to 'Epigenetic' Changes to the Oxytocin Gene, According to Latest Research, Mental Health Charity HorseBack UK Still Suffering Effects of Storm Arwen. The urine test is just a kidney screen to test for sugar and protein. If you have non-insulin treated diabetes the medical examiner will check that your diabetes is adequately controlled. Another reason antidepressants may be used is because ADHD and depression can occur together. Talk with your MD and explain that you are a commercial OTR driver. As clinicians, we can agree on the behavioral manifestations of ADD/HD. xref This is the first nonstimulant prescription ADHD medication approved for adults in 20 years. Can this disqualify me from driving a school bus? More than 9 million adults and 6 million children aged 417 suffer from attention deficit hyperactivity disorder (ADHD). Even with medication, people with this condition continue to struggle with symptoms associated with ADHD. Before submitting a request for a quantity level override, please ensure that a prior approval authorization has been submitted and/or approved (pages 1-2). These drugs help to reduce aggressive traits and hyperactivity and are usually prescribed for adults with high blood pressure. I have a question. Sorry I forgot to mention that the diagnosis and prescription was not from a dot medical examiner it was from my now former, family physician. The Medical Examiner has 2 ways to determine if any medication a driver uses will adversely affect safe operation of a CMV: Federal Motor Carrier Safety Administration. Learn everything you need to know about the prescribed medications, from the dosage to take, to the special warnings and possible side effects. Sleep Disorders (2018). 0000141415 00000 n WebThe .gov means its official. A commercial drivers license is one necessity that many truck drivers need to do their job. 2014-2023 NRCME Training Online. 0000009984 00000 n Yet, sometimes normal prescription medications can trip a positive test. Do all ADHD medication, disqualify your CDL license and medical card. Recent studies have shown that over 80% of children treated with stimulants notice dramatic improvements in a short time. This is why hypersensitivity happens, and how to manage it. Clinicians should note that the standard for FDA approval is lower for devices than for drugs. <<9E6C0941FF1DB74CA19247DDD271090E>]/Prev 1357945>> My Class A is still good but I need/want my medical card back. Am I able to get my medical card while taking Oxycodone 10/325? A drug screen has to be certified by a Medical Review Officer (MRO). Another odd benefit of the pandemic is that many children with ADHD have developed an increased appreciation for going to school. Its not uncommon for individuals with ADHD to also live with an anxiety disorder. You are going to have to explain to the medical examiner why and how much if any of these medications you are taking and the basic circumstances for their needs. If the urinalysis is positive for one or more of the drugs on the5 panel drug test, then the driver will be contacted in person by the Medical Review Officer. 0000009168 00000 n Cardiovascular If under the care of my personal doctor, can DOT medical examiner overrule my doctors opinion of prescribed care? Here is some information to help you understand better the concept of ADHD, how medications work on it, common side effects on adults and children, causes, and how to reduce its symptoms. The medical examiner needs to see your blood sugar levels below 120. Do I need to report this on the paperwork for prescriptions and medical history, bring a note from the cardiologist that confirmed a misdiagnosis of hypertension or is this something that doesnt have to be reported? Can Individuals with ADD/HD be good Commercial Motor Vehicle Drivers? In case you cant read that it says a doctor is required to report all dot physicals performed on a monthly basis, DOT medical Examiner Disqualified Me for being ADHD. WebThe following medications are approved on a case by case basis: Alpha Blockers Doxazosin (Cardura) Phenoxybenzamine (Dibenzyline) Terazosin (Hytrin) Prazosin (Minipress, There is a significant body of research to support this approval. In CDL School Now 2005-2023 Psych Central a Red Ventures Company. 0000005479 00000 n Thanks. People with attention deficit hyperactivity disorder (ADHD) may have different levels of dopamine than neurotypical people. Some common side effects of ADHD medications in children include: For adults, decreased appetite, anxiety, insomnia, irritability, and mood swings are the common side effects of using these drugs. No DOT medical examiner can or should try to overrule your primary cares opinion or medications/Rx. Strattera was the first non-stimulant approved to treat ADHD in children and adolescents in the United States, approved by the FDA for adults in 2006 and for children 6 and over in 2008. Secure .gov websites use HTTPS Its been approved for children as young as six years old. There are exceptions to the rule regarding other drugs prescribed by a physician, but this does NOT apply to Methadone. Table. REUTERS/Lindsey Wasson. It is my opinion that the gold standard of ADD/HD testing comprises medical testing including structural and functional brain imaging, patient questioners, performance testing (IQ, IVA+), and formal interview. If an athlete is battling a cold or flu, the U.S. Anti-Doping Association advises athletes to stop taking the drugs a few days before they compete. Stay up to date with the latest news and info from NRCME by signing up to our free e-newsletter: Attention Deficit Disorder and Commercial Motor Vehicle Driving. (2009). Can you obtain a Virginia DOT physical card, while taking Suboxone, to drive a Non CDL vehicle, that carries a US DOT number. (2008). Is it true that the CME can access all my prescription history? I have been diagnosed with panic attacks. ADD/HD is a diagnosis of exclusion. Thank you! Youll have peace of mind knowing weve got your back. It's one of the most commonly diagnosed developmental disorders of childhood. (2016). hb```f``If`e`. @16O. The time-release version is called Treatment for: ADHD. Just because a patient has been treated by multiple doctors over a long period of time does not mean his psychiatric disorder is correct. 2004;44(5):405. Non-stimulants take a longer time to manifest and are usually prescribed when stimulants are not effective in patients with ADHD. They Demand them and mandatory minimums for duis within 10yrs. Lets take a look at some of the side effects of Xanax which include: Drowsiness, light-headedness, headache, tiredness, dizziness, irritability, talkativeness, difficulty concentrating, dry mouth, increased salivation, changes in sex drive or ability, nausea, constipation, changes in appetite, weight changes, difficulty urinating, and joint pain. KemPharms AZSTARYS, a once-daily There are too many distractions at home, including the option of playing a video game while appearing to be in the virtual classroom. What medications disqualify me from getting a medical card? In the United States, more than nine million adults are affected by this condition. WebUnder FMCSA regulations (49 CFR 391.41), a medical examiner may not certify a driver who has a DOT disqualifying medical condition or uses a medication/substance that The following symptoms are uncommon, but if you experience any of them, call your doctor immediately: shortness of breath, seizures, seeing things or hearing voices that do not exist (hallucinating), severe skin rash, yellowing of the skin or eyes, depression, memory problems, confusion, problems with speech, unusual changes in behavior or mood, thinking about harming or killing yourself or trying to do so, and problems with coordination or balance.. If a driver uses a drug identified in 21 CFR 1308.11 (391.42(b)(12)) or any other substance such as amphetamine, a narcotic, or any other habit forming drug, The driver is medically unqualified. Drug test samples are normally split in half just in case a false positive happens. If you suspect you received a false positive, theres no need to panic. GeneSight is a diagnostic DNA test from Myriad Genetics. Having lower levels of dopamine is just one possible factor for developing ADHD. A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial. Discussion in 'Trucking Industry Regulations' started by Buzzbrn, Sep 26, 2014. Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric disorder in children and adolescents in the United States. DOT makes it clearthat any drivertakinga controlled substancenamed in21 CFR 1308.11 (391.42(b)(12)),or another habit-formingsubstance, is medicallyunfitto drive. To ensure your security, all travelers are required to undergo screening at the checkpoint. Laptop-based performance testing programs are affordable, can be ordered online and represent billable patient encounters in most states. Treatments recently approved by the US Food and Drug Administration (FDA) for pediatric patients with attention-deficit/hyperactivity disorder (ADHD) include 2 medications that address some of the common issues associated with standard stimulant treatments. To save us all from zombie spammers, your question will not appear on this page until it has been approved. Medications such as loratadine, desloratadine, and fexofenadine may be used while flying, if symptoms are controlled without adverse side effects after an document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); What you need to know about getting your Medical Card. Adjust timing based on duration of action. In this case, the Medical Examiner may, but does not have to certify the driver. No. But, studies have shown that factors like genetic mutation and environmental factors can lead to the development of ADHD. 2021;31(3):179-186. Otherwise the drug test will be reported as positive. The examiner can still declare the driver unfitbased on theirconsumption of the medication. Adult ADHD drivers rate themselves as more angry, risky and unsafe drivers, and report experiencing more losses of concentration and vehicular control than college students. Global ADHD Medications Market Research Report 2023-2028: Key Insights and Trends. An environmental physician would claim ADD/HD is due to toxins or vaccines. WebIn each class, drugs are listed alphabetically by either brand name or generic name. FDA Approved: Yes (First approved April 2, 2021) Brand name: Qelbree. The side effects of the medication could be a disqualifier from driving a bus. It is always best to communicate with your doctor to know when to taper off your dosage. 1. Unfortunately, busy clinicians may diagnose Attention Deficit Disorder based only on the patient's history or through a questionnaire based test. Use of medication by CDL operators brings up understandable concerns as to whether or not certain drugs will disqualify a driver from operating a CMV. These drugs join the alpha-2 agonists (eg, clonidine hydrochloride extended-release [Kapvay], guanfacine extended-release [Intuniv]) as options for families who do not feel comfortable giving children Schedule II stimulants or for patients for whom substance abuse is a concern. Your examining doctor should ask quite a few questions regarding your insulin usage to help determine your options. endstream endobj 203 0 obj <>/Metadata 200 0 R/Pages 199 0 R/StructTreeRoot 12 0 R/Type/Catalog>> endobj 204 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 7.8299813 595.5 850.07996]/Type/Page>> endobj 205 0 obj <> endobj 206 0 obj <> endobj 207 0 obj <> endobj 208 0 obj <>stream
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