Fillable Smallpox Case Investigation Supplementary ( Form 1B ) Page 1 of 2 - www2 cdc

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Case Report Smallpox Case Investigation Supplementary Form 1B Patient Information STATE 1. DATE OF FOLLOW-UP Month Day Year 2. NAME OF PERSON FILING THIS CASE Last First Middle Initial 3. PATIENT S NAME Yes 4. ADMITTED TO 2ND HOSPITAL OR ISOLATION SITE No Unknown IF YES DATE OF ADMISSION HOSPITAL NAME 2nd HOSPITAL MEDICAL RECORD City State Clinical Course 5. SMALLPOX TYPES RASH MOST SEVERE STAGE Ordinary Type...
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