PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name 7 Sex x Age S/ Residence: 1954-1960 — Arlulo thin UMA 1960-1966 1966-1972 197 2- . caort description of symptoms: Surgery Theyret dechons Year| LITVS Haye you been receiving treatment for any illness for a cerics OveL one year? ‘ Hus anvone in your family complained of similar symptoms to .v..O4eS you are now experiencing? 2 dletioes — Sedfoy K haan, Sucgery? Signature M501 500 Date PRIVACY ACT MATERIAL REMOVED