Atoll Name
Island Name
Clinic Name
Clinic Lecation
Interviewer Name
GENERAL. INFORMATION FORM
l.
2.
Is there an airstrip within the clinic serving area?
(]
Yes (please specify condition)
( ]
Noe ac present buc could be one in future (please spec#fy state of
( ]
|
Mo airstrip and no possibility of having one(state reqson why )
planning or construction and where it could be locaced
Are there free food services for che people in the clinic L.. area?
(]
{ ]
Yes
No
VS
Tf yes, specify types of focd and amounts
3.
Are there any churches or other volunteer agencies which ard involved in
Health Care in the clinic serving area?
[ ]
{[ ]
No
are any health services offerred by schools in the clinic sdrving area?
{]
( ]
Yes
Wo
Bend ond Gt bed bed final
Tf yes, specify by checking as many as apply below:
wars ees
4
Yas (please specify)
Eye tests
Immmizacion
Family Planning Education
Sexually transmitted disease prevention inseruction
Yearing tests
Other (please svecify)
7
Oye