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C HEALTH AGENCY USE ONLY CONDITION I.D. OUTBREAK I.D. DISEASE CASE REPORT Patient Information PATIENT IDENTIFIER PATIENT S COUNTRY OF ORIGIN DATE ARRIVED IN USA OCCUPATION HOME TELEPHONE WORK TELEPHONE PARENT OR GUARDIAN MARITAL STATUS SEX Male Female RACE/ETHNICITY (CHECK ALL THAT APPLY) AMERICAN INDIAN ASIAN BLACK ADDRESS YES PACIFIC ISLANDER UNKNOWN WHITE OTHER RACE Specify: NO UNK CITY, STATE, ZIP CODE COUNTY OF RESIDENCE YES WAS PATIENT HOSPITALIZED? YES Repo.

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