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X (circle): Onset DOB: M F Date: Disease suspected or test requested: Route to: [ ] SERO [ ] ISOL [ ] FA [ ] RAB [ ] EM This section for Virus Laboratory use only. Date received by VRDL and State Accession Number Specimen type and/or specimen source Date Collected Specimen type and/or specimen source Date Collected 1 st 1 st [ ] BE [ ] LC [ ] _____ [ ] _____ [ ] _____ 2 2 [ ] _____ [ ] E IgM Viral and Rickettsial Disease Laboratory [ ] E PCR California Department of Public Health [ ] .

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