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Get Tetanus Surveillance Worksheet Form

Tetanus Surveillance Worksheet Appendix 18 NAME Last First Hospital Record No. Address Street and No. City County Reporting Physician/Nurse/Hospital/Clinic/Lab Phone Zip Phone Address DETACH HERE and transmit only lower portion if sent to CDC CDC NETSS ID Birth Date Month Age Day Age Type Year Date Reported Year of Onset Acute Wound Identified Tetanus Toxoid Vaccination History Prior to Tetanus Disease Exclude Doses Received Since Acute Injury Me.

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