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Get Leptospirosis Case Repot Ohio Form

-0009 Exp. 4/30/2016 Visit www.cdc.gov/leptospirosis for a fillable PDF version of this Case Report Patient's Name Date Submitted to CDC Address State Case ID City Clinician's Name Clinician's Phone Demographics State of Residence Race Zip Code Alaska Native or American Indian Asian County of Residence Sex Date of Birth Black/African American White Native Hawaiian or Other Pacific Islander Not Specified Age days months years Hispanic or Latino Not Hispanic or Latino Unknown.

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