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Get Tn Mh-5426 2015-2024

_____________ Address: _________________________ Phone#: _______________ Fax#: _________________ Program type:  Residential  Non-residential  Personnel INTERVIEWER INSTRUCTIONS: Check YES or NO for each item below. Section I: Signs and Symptoms of TB Disease Does the individual now have? Yes No Cough lasting 3 weeks or longer? Yes No Chest pain? Yes No Difficulty breathing? Yes No Persistent fever and/or chills? Yes No Persistent loss of appetite? Yes No Weight loss (without dieting)? .

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