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(Use CDC 52.12 for waterborne disease outbreaks; CDC 52.13 for foodborne disease outbreaks.) OTHER REPORTABLE DISEASE OR DISEASE OF UNUSUAL OCCURRENCE Confirmed Not confirmed Suspected Kind of outbreak/illness PERSONAL DATA FOR SINGLE CASE ONLY Patient name last first middle initial Address number, street City State RACE (check one) Date of birth Age County Sex ZIP code ETHNICITY (check one) African-American/Black White Asian/Pacific Islander Other.

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