Atoll Name Island Name clinic Vame Clinie Location Interviewer Name CLINIC FACILITIES FORM Describe clinic location in ralation to other facilisies, te.J stores, docks, airstrip, homes. Sketch a map on back of chis page inodicaring ralative location of clinic. Describe boundaries of clinic sarving area. (If clinic se g area is part of an island, describe what part and how many other clinics are on island. Name island if clinic serves only one island. If ¢ adjacent islands, name all islands in the atoll.) Skercch a this page. feet by feet Outside dimensions of building. tnt td hd bt ares eo el Building wall material: Weod Brick Concreta biock Stone Masonite Other (please specity) ae es re Roof material: Metal Woed and tar composite shingles Thateh Tile Other (please specify) ic serves map on back of