Department
of Health and Human Services Version
11/12/2024
Centers
for Disease Control and Prevention
Form
Approved
OMB Control No: 0920-XXXX
Exp. Date: XX/XX/XXXX
Urubuga rw’Abagenzi Bagarazaga Ibimenyetso.
Fata iminota mike kugira ngo wemeze aho uherereye kandi usubize ibibazo bimwe na bimwe byerekeye ibimenyetso uhura na byo kugira ngo tubashe kuguhuza n’umukozi ushinzwe ubuzima rusange mu gace uherereyemo. Ubuzima bwawe n’ubuzima bw’abawe ni ingenzi kuri twe.
Ni he uherereye ubu? Andika Kawunti yawe/Kode ya zip.
Wigeze ugira umuriro (ungana 100.4 ° F / 38 ° C cyangwa urenga), wumvise ufite umuriro, cyangwa utengurwa? ☐ Yego ☐ Oya
Wigeze urwara umutwe mushya cyangwa udasanzwe cyangwa kubabara imikaya? ☐ Yego ☐Oya
Ufite uduheri? ☐ Yego ☐Oya
Wigeze ubabara mu gituza cyangwa mu muhogo? ☐ Yego ☐Oya
Wigeze ugira iseseme, kuruka, cyangwa impiswi? ☐ Yego ☐Oya
KOHEREZA [ibuto]
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Murakoze gutanga aya makuru. Umukozi ushinzwe ubuzima rusange azakuvugisha vuba kugira ngo muganire ku bimenyetso byawe kandi aguhe n’inama.
Hateganyijwe ko mu gukusanya aya makuru igisubizo kimwe kizajya gitwaa hafi iminota 10, harimo n’igihe cyo gusuzuma amabwiriza, gushakisha amakuru asanzweho, gukusanya, no kubika amakuru akenewe, no kuzuza no gusuzuma ikusanywa ry’amakuru. Ikigo ntigishobora kuyobora cyangwa gutera inkunga, kandi umuntu ntasabwa gusubiza mu ikusanywa ry’amakuru keretse yerekana nomero ya OMB yemewe. Gutanga ibitekerezo bijyanye n'iki kigereranyo cyangwa ikindi kintu icyo ari cyo cyose kijyanye no gukusanya amakuru, harimo ibitekerezo byo kugabanyiriza izi nshingano CDC, Umukozi Ushinzwe za Raporo, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920- XXXX).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Leticia Bligh |
| File Modified | 0000-00-00 |
| File Created | 2024-11-21 |