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COLLIN COUNTY HEALTH CARE SERVICES SUSPECTED ZIKA REPORT FORM Reporting Physician Information Physicians Name: Physicians Address: Physicians Phone #: City: State: County: Demographics Last Name:

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What is please answer all questions?

Please provide detailed and accurate information in response to all questions provided.

Who is required to file please answer all questions?

Any individual or entity that is requested to do so by the relevant authority.

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The purpose is to gather specific information or data for a particular purpose or investigation.

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