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ASH Conditions:
The fol owing conditions are ASH even if more than one of them is noted on the medical. Single Failure Point and Multiple
Failure Point outcomes can stil  be applied if any of the fol owing conditions are noted on the same health case.
Acne/Acne vulgaris whether or not on oral or topical medication
Abdominoplasty (Tummy tuck)
Abortion
Acanthosis nigricans
Adenoidectomy
Adipose tissue (fat)
Allergic rhinitis
Allergies: Drug al ergy, Skin al ergies, Hay fever
A  Alopecia including if on medication for hair loss (if sure this is related to hair loss treatment)
Amblyopia
Anaemia corrected
Act
Aorta – unfolding or tortuous aorta or sclerotic aorta for ≥50 years only
Aortic calcification/Aortic arch
Appendectomy/Appendicectomy
Atrial septal defect, repaired with specialist letter attached
Asthma well control ed e.g. Salbutamol (Ventolin) inhaler
Atypical moles
Azygous fissure/lobe
Back pain unless on narcotics, or associated with severe limitations
Bartholin’s cyst
Infomation
Bell’s palsy
Benign prostatic hyperplasia
Bifid ribs
Bilirubin light (treatment for new-borns with neonatal jaundice)
Birthmarks
Blepharoptosis of eyes
Official
B  Bone island
Bony abnormality
Breast fibroadenoma, Fibrocystic breast disease the
Breast implants
Breast reduction
Broken bones/old fractures/metal ware in limbs
Bronchial wal  thickening (mild)
Bronchitis
under
Bunions
Caesarean section
Capil ary telangiectasia
Cardiac fat pads
Cataract if visual acuity is normal and no other abnormal findings are noted
Cauliflower ear/boxer's ear/wrestler's ear
Cavities (teeth, dental, not in lungs)
Celiac/Coeliac disease
Cervical dysplasia
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Cervical fusion with no mobility problem
Cervical polyp more than 1 year ago
C
Cervical ribs
Cervical sympathectomy
Chilblains
Chicken pox if not active
Chlamydia, if treated
Cholecystectomy/Gal  bladder removal unless for cancer
Cholelithiasis
Chronic otitis media
Circumcision
Cleft palate repair, no further surgery planned
Club foot surgery in infancy, no further surgery required, functioning/mobilising normal y

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Cold Sore
Colon polyps
Colonoscopy more than 1 year ago
Colposcopy (pap test) more than 1 year ago and if not associated with cervix cancer
Concussion (no ongoing issues)
Conjunctivitis (pink eye)
Contraceptive oral medication or implant
Cosmetic surgery
Costochondral calcification
Creatinine (Low)
Cryotherapy for benign skin lesions
Cystectomy (Ovarian cyst)
Cystitis
Deafness in one ear only
Dengue fever
Dental disease
Dermatitis including contact
Act
Deviated septum surgery
Dextrocardia
D Diaphragm partial eventration
Discectomy with no mobility issues
Diverticulitis
Dorsal spine osteophytosis
Dyslexia only if no developmental delays
Dysmenorrhea
Dyspepsia
Infomation
Ectopic pregnancy with/without salpingectomy (history only)
Eczema requiring topical treatment only (skin creams, ointments) and not requiring oral treatment
Elective sleeve gastrectomy
E
Endometriosis
Enlarged tonsils
Epicondylectomy unless done for cancerous reasons
Official
Erb’s palsy
Facial paralysis
Factor V Leiden ( Factor 5 Leiden)
the
Fatty liver disease (non-alcoholic only)
Febrile seizure
Fenton’s repair for episiotomy scars
Fibroadenomas
F
Fibroid uterus
under
Fibroidectomy
Fibroids
Fibromyalgia
Finger amputation secondary to work injury stating no concerns or ongoing issues.
Foreign body in soft tissues e.g. bul et, shrapnel, etc. as long as in good health
Fracture (Healed)
Fungal skin infection (Tinea)
Gal bladder surgery
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Gastric bypass/Gastric Sleeve/Bariatric surgery
Gastritis, Dyspepsia, Heartburn, H-pylori, Stomach ulcer (gastric)
Genital herpes
Geographic Tongue (Benign Migratory Glossitis)
GERD/GORD (Gastro-oesophageal reflux disease)
Gestational diabetes with previous pregnancy
G Gilbert’s syndrome
Gingivitis
Glaucoma
Goitre (benign thyroid enlargement)
Gonorrhoea, if treated
Gout control ed with medication e.g. al opurinol
Graves’ disease (well managed)
Grommets (Tube insertions tympanic membranes right and left ears)

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Harrington Rod
Hashimoto’s thyroiditis
Haemorrhoidectomy
Haemorrhoids
Hair Loss
Hair Transplantation
Hayfever
Heart burn
Hepatitis A (history only) and juvenile hepatitis (if al  tests are negative)
Hernia – hiatus, inguinal, umbilical
Herniorrhaphy (hernia repairs)
Herpes of the eye
H  Herpes Simplex
Herpes zoster or shingles
Hirsutism
Hormone replacement therapy (HRT)
Hydrocele – Varicocele
Act
Hypercalcaemia
Hyperhidrosis (excessive sweating ) (with or without medication )
Hypoglycaemia – low blood sugar
Hypospadias only if already corrected
Hypotension
Hypothyroidism (thyroid insufficiency) with or without medication e.g. thyroxine
Hysterectomy unless for cancer (e.g. fibroids)
Hysteromyoma
IBS (Irritable Bowel Syndrome)
Infomation
Il iterate, can’t read for adults only ( outside of school age)
I
Incision and drainage of abscesses
Infertility
Ingrown toenail surgery
Insomnia
J
Jaundice only if 10 years or less, or neonatal
Official
Keloid scar
Keratoconus
Kidney infection if al  else is normal
the
K  Kidney, single with normal creatinine
Knee arthroscopy
Knee surgery and currently fully functional
Kyphosis, mild
Laparoscopy
under
Laser eye surgery unless complications
L
Lipoma
Liposculpture
Lumbago
Lumbar and thoracic pain with no mobility problem
Malaria more than 1 year ago
Malassezia furfur (pityrosporum fol iculitis)
Mammary implants
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Mammoplasty (Breast Lift)
Mastoiditis
Meatal cyst
Meniere’s disease
Menopause
M  Migraines
Miscarriage
Mol uscum contagiosum
Mongolian birth spot
Mononucleosis more than 1 year ago
Multiple nevi
Mumps (No ongoing issues)
Musculoskeletal injections
Myectomy if not cancer

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Myomectomy
Myringotomy tubes (Ear tubes)
N  Nasal operations or corrections
Occasional marijuana smoking when younger, not now
Occasional mild pain kil ers
Oophorectomy if not cancer
Orchidoplasty
ORIF (Open reduction internal fixation)
O  Osteochondroma if benign
Osteomyeltis (history only)
Osteopenia
Osteoporosis
Osteosynthesis with normal Activities of Daily Living
Otitis externa and Otitis media
Pancreatitis (history only)
Parenchymal scarring
Partial deafness
Act
Pectus excavatum/Carinatum
Perforated ear drum
Pericardial fat pad
Piercing
Pilonidal cyst
P
Pityriasis versicolor
Pneumothorax (history of)
Polycystic ovarian disease
Prostatic hypertrophy or BPH (Benign Prostatic Hypertrophy) / Enlarged prostate if smooth, no nodules
Infomation
Psoriasis of skin only, not psoriatic arthritis
Pterygium including Surfer’s eye
Ptosis (Droopy eye)
Pulmonary Embolism
Pyelonephritis more than 2 years ago
Pyloric stenosis
Official
Refraction problem/error for eyes/ Astigmatism
Removal of benign skin lesions such as skin tags and strawberry naevus
R  Restless leg syndrome
the
Rhinoplasty
Rib abnormalities e.g. Cervical ribs, Bifid ribs, Congenital rib fusion and previous rib fractures
SAD (Seasonal Affective Disorder)
Scarlet fever (history only)
Scars – old burns/injury/laceration
under
Sciatica
Seborrhoeic dermatitis
Septic arthritis more than 5 years ago
Septoplasty
Shirodkar stitches if it was the mother or with no complications
Sickle cel  trait (trait only – if disease, then refer)
S
Sinus surgery
Sinusitis
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Spina bifida ONLY on CXR and with no physical restrictions
Splenectomy secondary to MVA/RTA/Injury(only if a result of these)
Spondylitis/Spondylosis if mild and no associated problems with back
Spontaneous vaginal delivery
STD (Sexual y Transmitted Disease), if treated / STI (Sexual y Transmitted Infection), if treated
Sterilisation
Strabismus
Surfers ear
Syndactyl (Webbed) digits
Tattoos
“Tenting” on A grading CXR
T
Thyroid conditions other than cancer
Thyroidectomy
Tinea

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Tonsil ectomy
Tonsil itis
Tortuous aorta
Traumatic amputations (must not be disease related)
Tubal Ligation
Turbinectomy
Typhoid fever more than 1 year ago
Ulcer – peptic, duodenal, gastric
Uncoiling of the aorta
U  Undescended testicle(s) in child, solitary testicle
Urinary stress incontinence
Uterine fibroids (Fibromyoma uteri)
Uterine myomectomy
Varicose vein injections
Vasectomy/Tubal ligation in the absence of heritable disorder
V  Venous ulcers if not diabetic
Vertebroplasty
Act
Vertigo
Vitiligo
W  Warts
Wisdom teeth (removal)
X  Xanthelasma

Infomation
Official
the
under
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PURPOSE OF THIS DOCUMENT
This document provides information about how to assess applicants for residence and
temporary student visas who have special education needs. It offers guidance about how to
request further information, get an assessment from the Ministry of Education and write ASH
opinions. It also clarifies how children applying for visitor visas or providing Limited Medical
Certificates (LMCs) can be assessed.
BACKGROUND
The Ongoing Resourcing Scheme (ORS) is funded by the Ministry of Education. The need for
ORS funding is listed in A4.10.5 of Immigration Instructions as a condition likely to impose
significant costs and demands on New Zealand’s special education services.
Special education services include:
• Speech Language Therapy (SLT)
• Occupational Therapy (OT)
• Physiotherapy (PT)
• a teacher aide
• Resource Teachers of Learning and Behaviour (RTLBs), or
• assistive technology, such as a laptop with voice recognition software.
Depending on their physical, intellectual, sensory or behavioural condition, or group of
conditions a student’s requirements can range from very minor input such as simply needing
SLT assistance to needing ORS funding.
Visa applicants who qualify for ORS funding
Any applicant for a residence or temporary entry visa who may meet the criteria for ORS
under the Official Infomation Act
funding must be referred to the Ministry of Education for assessment before you give an
opinion about their standard of health.
ABOUT ORS FUNDING
The ORS supports students with the highest level of need for special education so they can join
in and learn alongside other students at school. To be accepted for funding they must meet
Ministry of Education criteria. If they qualify for funding, it stays with them throughout their
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time at school up to the age of 21.
To meet ORS criteria, students must have:
• ongoing extreme or severe difficulty in any of the following areas – learning, hearing,
vision, physical, or language use and social communication, or
2

• moderate to high difficulty with learning, combined with very high or high needs in any
two of the following areas – hearing, vision, physical, or language use and social
communication.
Criteria and definitions for ORS – Ministry of Education
Around 1% of students receive this support at any one time.
What ORS funding offers
ORS funds two levels of need: very high needs and high needs.
ORS provides services and support, including:
• specialists such as SLTs, psychologists, OTs, PTs, advisers on deaf children, special
education advisors, orientation and mobility instructors among others
• additional or specialist teachers who coordinate the student's learning programme
with the class teacher
• teacher aides to support the student’s learning programme and include students in
class programmes and activities, and
• consumables, such as computer software, extra-size pens and pen grips, Braille
machine paper, laminating pouches, or CDs and DVDs.
About ORS – Ministry of Education
ASSESSING SPECIAL EDUCATION NEEDS FOR ASH REQUIREMENTS
If student or resident visa applicants might meet the criteria for ORS funding, they must be
referred to the Ministry of Education for an opinion from an ORS Assessor.
Request an ORS assessment if the applicant is of school age but under 21 years of age, and has:
• applied for a student visa or a resident visa
under the Official Infomation Act
• a physical, intellectual, sensory or behavioural condition that indicates possible
eligibility for ORS funding – this could include learning difficulties, special needs,
developmental issues or delay, or low IQ.
You must also refer applicants who:
• already receive ORS funding
• have a condition you know qualifies for ORS funding
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• are 4 years old and have a condition which may qualify for ORS funding.
Before you request an ORS assessment
Before you make a FIR to an ORS assessor, gather all the information relevant to the
applicant’s special education needs and any medical conditions they have.
3

If the case is referred to the Ministry without the necessary information, the ORS assessor may
not be able to provide an opinion. This can slow down the visa application process and may
cost the applicant more money if they need to get further information for a second
assessment.
Assessing medical conditions for applicants with special education needs
When an applicant has been assessed as being eligible for ORS funding, also consider:
• the nature of the applicant’s medical condition
• their current level of daily functioning, and
• how they will manage in the future.
School-aged visitor visa applicants
You cannot request an ORS assessment for school-aged children applying for a visitor visa even
if it appears there is a possibility they may be eligible for ORS funding.
Applicants who provide Limited Medical Certificates (LMCs)
Applicants who provide a Limited Medical Certificate (LMC) are subject to different criteria.
However, if a child who has provided a LMC has any conditions which might qualify for ORS
funding, request an ORS assessment.
Student visa applicants 21 years and older
Students older than 21 cannot receive ORS funding. Assess these applicants under the medical
visa requirements and not special educational or ORS criteria.
MAKING FURTHER INFORMATION REQUESTS (FIRS) TO APPLICANTS
WITH SPECIAL EDUCATION NEEDS
under the Official Infomation Act
Requesting supporting information from specialists
Depending on the special needs of the applicant you may need to make FIRs to:
• a developmental paediatrician, who can provide a medical opinion regarding any
developmental disability, including physical, intellectual or cognitive disabilities
• an educational psychologist, who can provide an assessment of:
o
the applicant’s overall intellectual and cognitive ability
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o
their current developmental status
o
a prognosis of the conditions
• a SLT, who can assess any communication issues
• an OT, who can assess any difficulties with daily functions and physical limitations
• a physiotherapist, who can assess their physical limitations.
4

Note
It can sometimes be difficult to get specialist information for applicants living in some
countries. For example, consider requesting a paediatrician assessment’s rather than an
assessment from an educational psychologist for an applicant living in countries with limited
specialist resources.
It may be difficult to determine whether a young child could live independently in the future. If
you are requesting a FIR from an educational psychologist or a paediatrician, ask them to
comment on:
• whether the applicant currently requires a level of assistance with their ADLs that is
significantly higher than other children of the same age
• how this is likely to change over time, and
• if, as an adult, they:
o
may be able to live independently, and
o
will need help with their ADLs.
Requesting information from a school
Always make a FIR for a letter from the applicant’s school or preschool. Ask for details of:
• any educational supports they need or already receive
• how the applicant functions and participates while at school, and
• a copy of the applicant’s most recent Individualised Education Plan (IEP).
If an applicant disputes the Ministry of Education’s ORS assessment
If an applicant provides information to dispute the Ministry’s opinion that they qualify for ORS
funding, the new information must be referred back to the ORS assessor for a second opinion.
Your opinion is based on the new ORS assessment. If the applicant is applying for residence,
also refer the medical information for a medical referee’s opinion.
under the Official Infomation Act
ASH OUTCOMES FOR APPLICANTS WITH SPECIAL EDUCATION NEEDS
Outcomes for residence and student visa applicants
If an applicant meets ORS criteria and is applying for a resident visa or temporary student visa,
the outcome will be likely NOT ASH.
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If there is more than one reason that an applicant is likely to be NOT ASH then provide all the
reasons for a NOT ASH outcome in your opinion. For example, children with medical conditions
which have resulted in the need for special education services, may also impose a high cost on
health services.
5

Applicants who qualify for ORS funding
If an applicant for a resident or student visa qualifies for ORS funding, use this wording to
support your NOT ASH opinion.
Likely to impose significant costs or demands on New Zealand special education
services.
Also include:
• all the relevant information about the medical condition that has resulted in the
applicant being eligible for ORS funding and make it as detailed as possible
• confirmation from the ORS assessor that the applicant meets the criteria for ORS
funding, or that the applicant already receives this
• any additional information provided by the ORS assessor, such as costs, and
• any information relating to a second assessment, including the information provided
by the applicant to dispute the original Ministry of Education assessment.
Applicants who do not qualify for ORS funding
If an ORS assessment is returned advising that a student visa applicant is unlikely to be eligible
for ORS funding, consider whether any of the applicant’s conditions will impose significant
costs or demands on our health services and, if not, whether an AWC outcome is appropriate.
If an ORS assessment is returned advising that a residence applicant is unlikely to be eligible for
ORS funding, consider whether the applicant has any conditions on the A4.10.1 list of high-cost
health conditions or has any conditions likely to cost more than the threshold of $81,000 to
manage. If so, detail these in your likely NOT ASH opinion.
Outcomes for applicants providing LMCs
If an applicant who provides an LMC has been assessed as eligible for ORS funding then
under the Official Infomation Act
comment on in your opinion. Refer to the Immigration New Zealand Guidelines for Medical
Assessors for information on recording outcomes for LMCs.
Outcomes for school-aged visitor visa applicants
You cannot give an opinion of likely NOT ASH for a visitor visa applicant on the basis that they
may qualify for ORS funding if an assessment was done. Instead, consider an AWC outcome.
This means that your likely ASH opinion would only apply for the length of the visitor visa. In
your opinion, specify the updated medical information they need to provide if they apply for
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another visa.
If you are proceeding with a likely NOT ASH opinion for a school-aged visitor visa applicant do
not refer to any likelihood of costs or demands being imposed on special education services. In
your opinion, include:
6

• that they are likely to impose significant costs or demands on New Zealand health
services, and
• provide details of the medical condition that means they are likely NOT ASH.
under the Official Infomation Act
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7

Cochlear Implants
Information for INZ Medical Assessors
Background information 1,2 :
A Cochlear implant is a surgically implanted electronic device that provides a sense of sound to
a person who is severely hard of hearing or profoundly deaf.
A cochlear implant consists of two parts: an external sound processor and a surgically
implanted electrode array. The array is inserted into the cochlea and provides electrical
stimulation directly to the auditory nerve – bypassing the most common causes of hearing
loss.
Cochlear implants provide a good, although not perfect, reproduction of natural hearing. They
are more than capable of providing access to speech. Many users even have access to more
complicated hearing such as music.
Cochlear Implants in NZ :
MOH Funding2
under the Official Infomation Act
The Ministry funds cochlear implant services for people who meet all of the following
criteria:
•
You have severe to profound hearing loss in both ears.
•
Your hearing isn't helped by standard (acoustic) hearing aids.
•
You've been assessed as likely to benefit from a cochlear implant.
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•
You're eligible for publicly funded health and disability services.
•
You live permanently in New Zealand.
•
You do not qualify for cochlear implant funding through ACC.
The funded service includes:
•
the assessment
•
the device (an implanted electrode and a sound processor which is worn externally)
•
the surgery
1

•
audiology
•
maintenance and support
•
associated ongoing support services
•
rehabilitation for adults or habilitation for children
•
device replacement.
The funded service also includes fol ow-up services such as replacement sound processors for
adults and children.
For children, the funded service also covers the cost of any repairs, batteries or spare parts for
their speech processors.   Adults (aged 19 years or older) don’t have these additional costs
covered.
The Ministry does not fund fol ow-up services for adults (aged 19 or older) who received their
implant outside of New Zealand or who paid for their implant privately.
The Ministry contracts two providers to offer implant services.
1. The Northern Cochlear Implant Programme (NCIP) covers Northland, Auckland, Waikato,
Bay of Plenty, Rotorua and Taupo.
2. The Southern Cochlear Implant Programme (SCIP) covers the rest of New Zealand.
These providers select the hospitals where surgery for cochlear implants takes place. The
under the Official Infomation Act
hospitals may be public or private hospitals. The cost of travel to the hospital for an audiology
assessment, surgery and follow-up appointments may be covered through the National Travel
Assistance Scheme.
NZ Statistics1,2
In New Zealand there are roughly 1,000 cochlear implant users, of which there are
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approximately 350 children (0-18yo). Of the 350 children, approximately 16% have both ears
implanted. In the 0-5y group this increases to 30%1 (2014 data). However, since 2014 the
Government has funded bilateral implants for under 18y olds4, so these statistics wil  change
over time.
The New Zealand Government funds only one Cochlear Implant per user for adults. They fund
46 per year for children and there is no waiting list. The government has just increased funding
for adults, from 40 to 100 per year. There are currently 224 adults on the waiting list4.

Costs Associated with Cochlear Implants in NZ1,3 :
Each cochlear implant costs approximately $45,000 for surgery, implant and switch-on3. If a
second implant is done at the same time, the extra cost is approximately $35,0001.
The processors need to be replaced every 6-7 years, at a cost of around $10,000 each time3.
In August 2017 the Government announced an increase of total funding to $14.93 million for
cochlear implants and associated support each year3.
All parents of children with cochlear implants can access the Child Disability Allowance1.
All people with disabilities, including cochlear implants can access the Disability Allowance4.
Special Education Considerations
People with cochlear implants undergo hearing rehabilitation, to enable them to obtain
(children) or return (adults) to normal speech and language skills. This could include SLT, OT
and Teacher Aids. Children with cochlear implants may require special education, or be in
mainstream classes.
under the Official Infomation Act
Minister of Health Press release3    25 August, 2017
$6.5m to increase adults cochlear implants
Health Minister Jonathan Coleman says $6.5 million will be invested into the adult cochlear
implants programme to increase access.
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“For those with profound hearing loss cochlear implants can be a life changing procedure,”
says Dr Coleman.
“Access to funded cochlear implants have increased significantly under this Government. In
2014 we expanded the children’s programme so our under 18s could receive bilateral
implants, with no waiting list.
“In 2013 we also increased the number of funded cochlear implants for adults from 20 to 40 a
year. However, we want even more adults to benefit.

“That’s why we’re investing an extra $6.5 million into the adult programme for 2017/2018.
This will increase the Cochlear Implant Programme's total funding to $14.93 million.
“The total number of funded cochlear implants for adults will go from 40 to 100 for
2017/2018, an increase of 150 per cent.
“The investment will also increase the capacity within the system and cover the additional
audiology and rehabilitation time required to support such a massive uplift.
“I have also asked officials for advice around how we can better structure the funding model
for this important service going forward.”
The extra $6.5 million will come from reprioritisation within Vote Health.
Notes to Editors
Around 86 New Zealanders receive funded cochlear implants each year. Up to 16 are infants,
30 are children aged 2-18 years and 40 are adults.
There are currently around 224 adults on the waiting list for a funded cochlear implant.
A cochlear implant costs about $45,000 for surgery, implant and switch-on.
The processors need to be replaced about every six to seven years, which costs about $10,000
each time.
under the Official Infomation Act
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Management of Cochlear Implants for Medical Assessors :
Considerations when assessing a case :
• Where and when did they receive the cochlear implant?
• When is the processor due to be replaced next?
• What is their current level of speech and language? eg
o Are they able to communicate normally?
o Do they have normal daily functioning – both adult and children?
o Are they likely to be able to live independently as an adult?
o Do they receive special education services?
o Are they receiving any ongoing rehabilitation eg SLT, OT?
• Do they have any other potential high cost / demand health conditions?
Outcomes :
NOT ASH :
• Any applicant who has been reported to need a cochlear implant.
o Costs : $45k for the implant surgery, $10k every 7 years for a replacement
processor, and ongoing rehabilitation costs
o Demand : There is a waiting list for adults who need cochlear implants
o Also consider any other associated issues eg

ORS, special education needs

Developmental / medical / surgical conditions
under the Official Infomation Act
ASH • Any applicant who is deaf and does not have a cochlear implant and does not require a
cochlear implant and does not require significant supports ie no treatment has been
recommended and they have normal function and ADLs.
• Any applicant who has a cochlear implant, with normal function and ADLs and no
other associated issues (see above)
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Extra Considerations :
• Any applicant who is deaf, or has a cochlear implant AND has other potential high cost
and / or high demand medical conditions requires assessment of ALL their conditions
before an overal outcome can be determined. Including :
o ORS, Special Education needs
o Developmental / medical / surgical conditions
o NOT able (likely to be able) to function independently in the community as an
adult

References :
1
https://2ears2hear.kiwi.nz/bilateral-cis/media-info/
2
http://www.health.govt.nz/your-health/services-and-support/disability-
services/types-disability-support/hearing-and-vision-services/hearing-
services/cochlear-implants
3
https://www.beehive.govt.nz/release/65m-increase-adults-cochlear-implants
4
http://www.health.govt.nz/your-health/services-and-support/disability-
services/types-disability-support/hearing-and-vision-services/hearing-services/help-
costs-hearing-loss
under the Official Infomation Act
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under the Official Infomation Act
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Document Outline