Atoll Name
Island Name
Clinic Name
Clinic Lecation
Interviewer Name
GENERAL. CYFORMATION FORM
l.
Ze.
Is there an airstrip within the clinic serving area?
( ]
Yes (please specify condition)
( ]
Not ae present but could be one in future (please specify state of
( ]
No airstrip and no possibilicy of having one (state reason why)
planning or construction and where it could be located)
Are there free food services for tha peovle in the clinic serving area?
(]
[ ]
Yes
No
TZ yes, specify types of food and amounts
3.
Are there any churches or other voluntaer agencies which are involved in
Health Care in the clinic serving area?
[ ]
{ ]
No
Are any health services offerred by schools in the clinic serving area?
{ ]
{]
Yes
Wo
fn Reed Bree Bend bed famed
Tf yes, specify by checking as many as apply below:
PsA rare Pes eee as
4.
Yes (please specify)
Eye casts
Tammnization
Family Planning Education
Sexually transmitted disease prevention inseruction
Hearing tests
Other (please specify)