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Get West Virginia Reportable Infectious Diseases Health Care ... - Dhhr - Dhhr Wv

Please Print and Complete Each Question: Disease Name: Patient s Name (Last, First): Date of Birth: Guardian/Parent s Name: (Last, First) Age: Address: City: Was patient hospitalized? No Yes. Indicate facility below Symptom Onset Date: Gender: Race: Male Female Unknown State: Zip: Ethnicity: White Black/Afr. American Asian Amer Indian/ Alask Native Native Hawaiian/ Pacific Isl. Unknown County Hispanic/Latino Not.

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