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VAERS Number 4. Patient age mm dd yy 9. Patient recovered YES NO 5. Sex M 6. Date form completed F 12. 1895 ROCKVILLE MD POSTAGE WILL BE PAID BY ADDRESSEE VAERS Rockville MD 20849-1100 DIRECTIONS FOR COMPLETING FORM Additional pages may be attached if more space is needed. GENERAL Use a separate form for each patient. Form VAERS-1 FDA 320621. qxd5 10/3/02 10 29 PM Page 2 Fold in thirds tape mail DO NOT STAPLE FORM NO POSTAGE NECESSARY IF MAILED .

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