文档介绍：INTERNALUSE:ReferenceCaseIllnessOnsetDate:____________Referentperiod_____/______/______to_____/_____/_____UseforQuestions#2–12,16 -7daysbeforeonset7daysafteronsetStateEPIID#(referencecase):____________________CDCEPIID#(referencecase):______________________ StateEPIID#(otherreferencecase):_________________CDCEPIID#(otherreferencecase):__________________StateEPIID#(contact):_________________________CDCEPIID#(contact):___________________________Interviewdate(mm/dd/yy)____/____/____ DateofReport(mm/dd/yy)____/____/____CaseStatus:¨Caseconfirmed;date____/____/____ ¨ProbableCase;date____/____/____ ¨SuspectCase;date____/____/____ ¨Notacase;date____/____/____ClusterID:__________________ ClusterName:__________________SOURCEOFINFORMATION¨Person ¨Proxy(notavailableortooyoung);ifyes,relationshiptocontact:________________________ProxyFirst________________ProxyLast_______________________Address____________________________________________________________City______________________________State_______Zip__________________Email________________________ Phone(___)_________ CellPhone(_____)________REPORTERINFORMATION(IfreporterisCDCstaff,listCDCUserIDinfirstfieldandskipotherfields)ReporterNameFirst__________________Last________________________Reporter’sOrganizationName______________________________________________________Address_________________________________City_____________________State______Zip________PhoneNumber:()_____–_______ FaxNumber:()_____–_______E-Mail:_____________________ County:_________________CONTACTDEMOGRAPHICINFORMATIONNameFirst_____________________________Last__________________________ Address__________________________________________________________________________City___________________________State___________Zip______________Country(ifnotUS)__________DOB(mm/dd/yy) ____/____/____ orAge______ yrs mo(forinfantsupto11mo;0mo=<1moold) Sex(circleone) M/F Race: White(1) NativeHawaiian/OtherPacificIslander(4) Multiracial(6) Black(2) AmericanIndian/AlaskaNative(5)