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Get North Carolina Disaster Surveillance Forms

Per day (12am 12pm) Instructions Tally total number of patients in each category Example: Facility Facility name (description) Patient Information Date Males Females Age 1 years Age 65 years Total PATIENTS seeking care Total RESPONDERS seeking care (e.g., relief worker, volunteer) Reasons for Visits Select one reason for each patient visit and tally total number of patients per syndrome category UNINTENTIAL INJURY FEVER (e.g., fall, cut, bite/sting, vehicle collision) (i.e.,.

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