PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name Sex & Age a Residence: 1954-1960 — [r/of 1960-1966 — Wndee 1966-1972 _ 1972 ~ — wt WE aw eos Snore description of symptoms: Cleffeels Surgery Morpedel, f ae Year J / bvedlmy FTF Have you been receiving treatment for any illness for a perioa over one year? ; Wo O Has anyone in your family complained of similar symptoms to the ones you are now experiencing? 7s Surgery? Lf, (ITE Bex Tir) Signature . 7 | ? biter Date 6h 18I 4 ’ if79 / of PRIVACY ACT MATERIAL REMOVED