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Get Polio Worksheet Form

Appendix 14-1 Suspected Polio Case Worksheet REPORT CONTACT Initial Report Date Name Last First hh hh hhhh Month Address City County State Reporting Laboratory Day Zip Code Year Phone PATIENT IDENTIFIERS Birth Date Age at Onset hhh Age Type h 999 Unknown H Hispanic N Not Hispanic U Unknown Date of Onset of First Symptoms N Native American / Alaskan Native A Asian / Pacific Islander B African American W White O Other Male h M Female F Sex Race Eth.

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