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Page 1 of 3 Version: 15 Nov 2013 CASE REPORT FORM Hemophilia Influenza Type b Disease Hemophilia Influenza Type b Disease Epicure No. Reporting Authority Name of Public Health Officer responsible

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The name of the reporting source is the entity or organization that is responsible for providing the information being reported.

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The name of reporting source typically includes the legal name of the entity or organization, along with any relevant contact information.

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