Fillable Form 3a - Emergency Preparedness and Response - bt cdc

Description
Form 3A: Smallpox Case Exposure Investigation Form Case Exposure/Source Information Case Information 1. STATE 2. Case # ___ 3. INTERVIEW DATE: Month OMB NO. 0920-0008 Exp. Date: 06/2003 Day Year 4. CASE NAME: ___ / ___ / ___ (Last) (First) (Middle) (Suffix) (Nickname) 5. ADDRESS: ___ Street Address, Apt #
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