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Get WA DOH 210-017 2005-2024

Ic health agency Other Yes No OK to talk to case? PATIENT INFORMATION LHJ Use ID _______________________ Reported to DOH Date ___/___/___ LHJ Classification Confirmed Probable By: Lab Clinical Other: ___________________ Outbreak # (LHJ) _______ (DOH) _______ DOH Use ID ____________ Date Received ___/___/___ DOH Classification Confirmed Probable No count; reason: Reporter name ______________________________________________________ Reporter phone ________________________________________________.

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