PRIVACY ACT MATERIAL REMOVED . - GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name .—_—ss_—e__iad.s,.,,, ion sex f- Age V / Residence: 1954-1960 hor 1960-1966 hg) 1966-1972 ~ 7% ~ 0 1972- meas Short description of symptoms: Fiver, tant G te cugitel hice) surgen: “aerf, ts pli Lin dering @ te year 7 Have you been receiving treatment for any illness for a period over one ee 63 Has anyone in your family complained of similar symptoms to the ones you are now experiencing? U/, oO. Surgery? Signature> — ; : Date vy |79 | / 7 7 PRIVACY ACT MATERIAL REMOVED