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Get TN MH-5426 2010

_________________ DOB: ______/______/_______ Alias(s): ___________________________________ Country of origin: _____________________ Facility: __________________________ Program type: ¨ Residential ¨ Non-residential ¨ Personnel INTERVIEWER INSTRUCTIONS: Circle Y= yes or N=no for each item below. Section Y Y Y Y Y Y I: Signs and Symptoms of TB Disease: N Cough lasting 3 weeks or longer? N Chest pain? N Difficulty breathing? N Persistent fever and/or chills? N Persistent loss of appeti.

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