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Form Approved OMB Control No. 0920-XXXX Expiration date XX/XX/XXXX Pregnancy and Zika virus disease surveillance form These data are considered confidential and will be stored in a secure database at the Centers for Disease Control and Prevention Please return completed form by fax to 970 266-3568 or email XXXX cdc.gov Neonate assessment at delivery Infant s name DOB // State of residence County of residence Sex Male Gestational age at delivery weeks Female Infant temp at delivery oF Cord...
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