REVERSE SIDE OF THIS FORM MUST BE COMPLETED 



Type Specimen 



"■ -•■ ~ ■ ^^ 



■ .fr'svVN^^. V ^-. ..^:^' 



THIS FORM MUST BE EITHER PRINTED OR TYPED 



PLEASE PREPARE A SEPARATE FORM FOR EACH SPECIMEN 

 (Consider paired sera one specimen) 



DASH. 



HSM 3.203-R 

 6-72 



3 



(12-13) 

 Comments: 



Date Reported 



Mo. Day Yr. 



(1419) 



(40-41) 



(198-200) 



CDC 3 203 

 REV 476 



PLEASE DO NOT USE BLUE INK 



145 



