Anthrax Suspicious Powder Data Collection Questionnaire
Suspicious Substance Data Collection Questionnaire
Please Print This information will be kept confidential
Today's Date: _____/_____/_____ Medical Record Number:
First Name Middle Initial _____ Last Name
Gender (M/F) Date of Birth _____/_____/ Age
Event Date: _____/_____/_____ Event Location
Where were you when the event occurred?
(For instance, Room Number, Parking Area 2 Red, NW corner of 3rd floor, etc. Please be specific)
Did you enter the immediate area after the event occurred? ( ................
................
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