_ PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Isiands Special Health Survey Name ere Sex A Age J¥ Residence: 1954-1960 —~ 1960-1966 1966-1972 Kreatalernn Nt47tt hie bp AFerure Snort description of symptoms: ELL] Atl (PAK y ATK TIVE, Lere CP KKraphlopics NET? bole {MESS , “ FEL /te &- Kerl: 17 Les Tle. Spee2 4 Al) THe Tivo Fife Surgery Bey Kop DPBhIeTmny Year MenGe (? EI Have you been receiving treatment for any illness for a pexvice Over one year? A’ Lo! AL bo Ao Has anyone in your family complained of similar symptoms to the ones you are now experiencing? fUO Surgery? Signature _ gpm . . oe STO Date ™ c fel bpivacy ACT MATERIAL REMOVED /