PRIVACY ACT MATERIAL REMOVED ee GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name ; Residence: Sex Male Age 14 Likiep 1954-1960 1960-1966 1966-1972 1972- Short description of symptoms: Surgery Cleft Palate Cleft Palate Correction (Three Times) Year 1968 “(Guam Memorial Hospital) Have you been receiving treatment for any illness for a period over one year? Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Surgery? Signature -- a - gummy 50115937 Date _ SULT 5 PRIVACY ACT MATERIAL REMOVED