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SIS (M.I.) (Number, Street, City, State) (ZIP CODE) REPORT OF VERIFIED CASE OF TUBERCULOSIS Case Completion Report Year Counted (Follow Up Report 2) State Case Number City/County Case Number Submit this report for all cases in which the patient was alive at diagnosis. 41. Sputum Culture Conversion Documented (select one) No Yes Unknown If NO, enter reason for not documenting sputum culture conversion (select one): If YES, enter date specimen collected for FIRST consistently negati.

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