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Get Canada Ebola Virus Disease (EVD) Contact Tracing Report Form

ATION NUMBER 1 Surname: Given Name: Sex (male/female): Age (years or months if under 2 years): Date of Last Contact with EVD case (dd/mm/yyyy): Epidemiologic Risks* (High-risk/Low-risk): City: Province/Territory: Phone Number: Healthcare Worker (yes/no) If yes facility: # Quarantine Unique ID (if applicable): NUMBER 2 Surname: Given Name: Sex (male/female): Age (years or months if under 2 years): Date of Last Contact with EVD case (dd/mm/yyyy): Epidemiologic Risks* (High-risk/Low-ris.

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