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8 Hartford, CT 06134-0308 CASE NUMBER: (For Office Use Only) COMPLETE FOR ALL TB CASES and TB CASE SUSPECTS Voice: (860) 509-7722 (LAST) Fax:: (860) 509-7743 (FIRST) SEX AT BIRTH: M STREET ADDRESS: CITY: RACE (SELECT ONE OR MORE) STATE: : MM ZIP: BLACK OR AFRICAN AMERICAN ASIAN: WHITE COUNTRY OF BIRTH: SSN: OR LATINO SPECIFY STUDENT VISA PREVIOUS TB? REFUGEE STATUS IMMIGRANT VISA ASYLEE OR PAROLEE UNKNOWN PEDIATRIC TB PATIENTS IF YES, YEAR: (.

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