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Get Ca Cdph 8554 2007-2024

AK (Use CDC 52.12 for waterborne disease outbreaks; CDC 52.13 for foodborne disease outbreaks.) OTHER REPORTABLE DISEASE OR DISEASE OF UNUSUAL OCCURRENCE Confirmed Not confirmed Suspected Kind of outbreak/illness PERSONAL DATA—FOR SINGLE CASE ONLY Patient name–last first middle initial Address–number, street City State RACE (check one) Date of birth Age County Sex ZIP code ETHNICITY (check one) African-American/Black White Asian/Pacific Islander Other _________________.

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