Transcription of Legionellosis Case Report
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Legionellosis Case Report
$%$ t /BUJPOBM $FOUFS GPS *NNVOJ[BUJPO BOE 3 FTQJSBUPSZ %JTFBTFT-&(*0/&--04*4 $"4& 3&1035 (DISEASE CAUSED BY ANY LEGIONELLA SPECIES) case No.: (CDC use only)1"5*&/5 */'03."5*0/1. State health dept . case No.:2. Reporting State: 3. County of Residence:4. State of Residence: 5. Occupation:6a. Date of Birth: 6b. Age: 7. Sex: 1 Days 2 Mos. 1 MaleMo. Day Year3 Years2 Female8. Ethnicity: 1 Hispanic/Latino2 Not Hispanic/Latino9. Race: (check all that apply) 1 Black or African American American Indian/ 1 Native Hawaiian or Alaska Native1 Other Pacific Islander1 Asian1 White1 the 10 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?)]
CDC 52.56 Rev. 11/2013 Legionellosis Case Report Page 2 of 2 Interviewer’s Name: Affiliation: Telephone No.: INTERvIEwER IDENTIfICATION Local Health Dept.
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