KANSAS REPORTABLE DISEASE FORM Today s Date      Patient s Name Last First Middle HomeCell Phone Work Phone Residential Address City Zip County Ethnicity Hi spanic or Latino Not Hispanic or Latino Unk
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KANSAS REPORTABLE DISEASE FORM Today s Date Patient s Name Last First Middle HomeCell Phone Work Phone Residential Address City Zip County Ethnicity Hi spanic or Latino Not Hispanic or Latino Unk

SA 65118 65128 656001 65 6007 KAR 2812 2814 and 281 18 Changes effective as of 929 20 14 Mail o r fax reports to your local health department andor to KDHE Bureau of Epidemiology and Public Health Informatics 1000 SW Jackson Suite 075 Topeka KS

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KANSAS REPORTABLE DISEASE FORM Today s Date Patient s Name Last First Middle HomeCell Phone Work Phone Residential Address City Zip County Ethnicity Hi spanic or Latino Not Hispanic or Latino Unk




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