E railroad insurance number): Resident Name, Last: First: *Gender: M F Other *Ethnicity (specify): Hispanic or Latino Not Hispanic or Latino Declined to respond Unknown *Date of First Admission to Facility: / / *Event Type: UTI *Resident Care Location: *Primary Resident Service Type: (check one) Middle: *Date of Birth: / / *Race (specify): American Indian/Alaska Native Black or African American Native Hawaiian/Other Pacific.

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