Hurricane Katrina Evacuee Medical Intake Form

The PDF is here. From the CDC:

This interim form is intended to be used for medical intake assessment and triage of evacuees entering a shelter facility or evacuation center. The form can be used to identify evacuees who may need additional medical evaluation and treatment. The first page contains registration information for use by facility, local and state authorities. The remaining pages can be used to anonymously report medical conditions among evacuees.

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