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Text File  |  1994-08-22  |  604b  |  21 lines
  1.  
  2.                  MICHIGAN NOTIFIABLE DISEASE CASE REPORT
  3.                           Supplemental Report
  4.  
  5.                              ID #########
  6.  
  7.  
  8.      FOODHANDLER <Y>          {DAYCARE} ASSOCIATED <Y>      {N}URSING {H}OME <Y>
  9.  
  10.         FACILITY <A                                 >
  11.  
  12.         SEROTYPE <A               >                    SPECIMEN <A         >
  13.  
  14.        PHYSICIAN <A                       >
  15.  
  16.    {C H}EALTH {D}EPT <A         >                  {INITIATED} BY <A   >
  17.  
  18.      {PROPHYLAX}ED ###
  19.  
  20.      SURVEY FORM <A>                              {DATE RETURN}ED <mm/dd/yy>
  21.