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Get CA CDPH 110b 2016-2021

REPORTED Patient Name - Last Name Tuberculosis First Name MI Home Address: Number, Street State Cell Telephone Number Email Address Work Telephone Number No English Spanish Other: ______________ Age Gender Years M to F Transgender Male Months F to M Transgender Female Days Other: ____________ Est. Delivery Date (mm/dd/yyyy) Country of Birth Pregnant? Unknown Occupation or Job Title Occupational or Exposure Setting (check all that apply): Correctional Facility Date of Onset (mm/dd/y.

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