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Get HHS CDC 52.5 (E) 2012-2024

– Please complete this form only for new, symptomatic, culture-proven cases of typhoid or paratyphoid fever. – Form Approved: OMB No. 0920-0728 DEMOGRAPHIC DATA 1. Reporting State: 4. Sex: Male 2. First three letters of patient’s last name: 3. Date of birth: 5. Does the patient work as a foodhandler? 6. Citizenship: Female Yes 7. Was the patient ill with typhoid or paratyphoid fever? (fever, abdominal pain, headache, etc) Yes No Unk. 10. Date Salmonella first isolated: Mo. Da.

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