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<br />ATfACHMENT 4 <br /> <br />- - - - - ---- ~ - -~ - - ~ - -J_ - ~ - -- --- - .- <br />- - - - - -- - - <br /> - <br /> - - <br />Name: Date: o Visitor Date of Birth: <br /> o Employee <br />.Job Title: Worksite: Location of Isolation: <br />Address: <br />Telephone no: <br /> (Work) (Home) (Other) <br />Symptoms: <br />o Fever - Time of onset o Body aches <br />o Dry cough o Fatigue <br />o Cold or chills o Other: <br />Healtbcare referral: <br />Notes: <br />Close contacts during previous 2 days: <br />Name: Email: Phone #: Address: <br />L <br />2_ <br />3. <br />4. <br />5. <br /> <br />Reporting Party Name: <br />.Job Title: <br />Tdephone no. <br />(Work) (Home) (Other) <br /> <br />SUBMIT COMPLETED FORM PROMPTLY TO THE CITY ADMINISTRATOR <br /> <br />Pandemic Influenza Continuity ofOperafions Plan <br /> <br />30. <br />