Document ZJQVmpxy6M3E85gM2XV3XMbe0

------ i tc-jo ------- 13600 13700 -------- lOU- 1. SD'PCE OF S"i'1 INC- whs: -(CHECK ALL-THAT-APP-T:--------- RECENT INTERVIEW WITH THE SUBJECT trf.c -fv.i*lC'.f<rrt z''z"!i7 ------------------- --- ------------- --- MEDICAL RECORDS 13900 ------- .4000- 14100 ------ 442C<- coworker who did not supervise employee -CLOSE ffNE-OP -E-aOYES--------------------------------------OTHER (SPECIFY: 14300 -------- 1M00-- WHEN WAS THE LAST TIME THE SOURCE SAW THE STUDY SUBJECT? 19____ (GIVE YEAR: 14500 3.A. THE LAST TIME THE SOURCE SAW THIS PERSON, DID T SMOKE CIGARETTES'' ------ 1*600- ----------- rrr-ftEGULARtY---------------- -USUALLY AT LCftST Ot CIC'RRTT-PSfr-OAYt:---------- 14700 ----- URJiO- OCCASIMLLv (SOMETIMES BUT LESS THAN ONE CIGARETTE PER DAY). _______ __ .(VER.------------------------------------------------------------------------------------------- 14900 -tSOSfr ---------------------------------- (IF YOU1 ANSWERED 'OCiACICKALLY' OR 'NEVER' TQ-J.A. ABoVE-SKIf-TO 0.SfKfft-4rA.-raOW.7-- 15100 15300 ---------------------------------- IF-YOU'ARCHERS' `RSft.tATcVMP S.A.,------------------------------------------------------------------------ -- 1C?X> 3.B. ABOUT HC'W MANY PACKS WAS HE USUALLY SMOlIINO EACH DAY? 15400- ---------------------------------- PACKS/SA.Y------------------------------------------------------------------- SKOARPTEi^DAY---------------- -- -- 15500 -rCfrJ- (PROXY'S RESPONSE ONLY) (SUBJECT'S RESPONSE OVL'.'I 15700 __ LESS- THIN CHE FAC)'. -PfSOO1E90C SJJuu'i __ TWO rCRs'pACr.S l`!00 (PlEASE GIVE BEST ESTIMATE. ONE PAC>' COCA I VS 30 CIGARETTES.! ------- H444016500 --------It*00 16700 --------1 ijlVi U900 ------- FOGO- 17100 ------- rTiOC- 17300 ------- r-4- 175-X- 17700 17900 3.C. DID HE AL-r? i"D THAT A.-jjVP__ YES___ v? _ _ _ _ DON'T KNOW IF YOU ANSWERED '.`JO' TO 3.C.. -rr&i--U/LI-LONS--BS-T-S TrC-^iuSfC-l.flC.f-g^ .yfJC 4ut (C-- T I[,- a,;f. i>|~.. I 7---"YEARS'- 3.E. ABOUT HOW MU> WAS THE SUBJECT SMOKING EACH DAy BE*ORE HIS SMMNG fC?r: --`"I C *' PACIS-'DAY CIGARETTES/DAY -tfRW'O 'Eiro-vic ONLY-)----------------------------------------------- ^v&vECT-i-ftS^.-SE Cv.- ------- ---------------------------------- ---- LESS r-6-N one c-ioaret-te-per day.------------------------------------------------------------------------------------------ AT LEAST ONE CIGARETTE BLIT LESS THAN ONE PAD;. NO. CIGARETTES/DAY =____ ---------------------------------- AT-LEWC7 CfiC BACH-OUT LECC THAN TWO RACnC-------------------------------------------------------------------- :------------- __ TWO OP MORE PACKS. -------- :----:--;--j.F. AT WHAT- AGE DID SUBJSGT-ST-TRT FOKINS- ':i&.Tg:TT=-------------- -^...^r-E-'IW^g.^Sr ----------------- ---------------------------------- tlC-YOU-HA^-COMtETED THIS SECTION, SKIP TO DjEG'ION H.- ON THE-CfotfWHfa R-X-S'--------------- ---------- ieu-o +S2A4- 1 s V'O 13500 )tr is?-* -HSG-X1 ':->0 ISOOO 19100 ljjv 19500 ftoj 4.A. DID THE SUBJECT E'.ER SMOKE REGULARLY (USUALLY AT LEAST ONE CIGARETTE PER DAr'' -------------------------- L_--_-...Yg----------- __4<9--------------------------------------------------------------------------------------------------- --- ------ ---------------------------------- tf-YOtMWDERED - YES'- TO 4.A.,--------------------------------------------------------------------------------------- :----------- B. HOW LONG BEFORE V(rj LAST SAW THE SUBJECT DID HIS SKOkING HABITS CHANGE" YEARS C. ABOUT HOW W.f> W6? SUBJECT SPRING EACH DAY BFORt HIS S-CH'.INO HABITS CHANGED? -------- w-CKS/W------------------------------------------------------------------- CIOAfiET-TCC/ft**--------------- (PROXY'S RSPO.':E ONLY) (SUBJECTS RESPONSE O1'. __ LESS Than 1 RACK. ---------------------------------- --- AT `_C*jT C`.*C PACr. BuT lvC--ThAV-TW PfeCf.i.--------------- Nfr^t~HC,^r~r.4!|gT -____ _ _ _ _ _ _ _ _ _ __ TWO OR MORE PACKS. -------------------------------------- DON T KKfr:-----------------------------------------------------------------------------------DUP 0906624 ------------------------- Dr--AT-WHAT-AGE EIE- ErrJg-S7"`:7ATr Lv0`.:,NO CIOATtETTCC?------------- -4C-E-, ISiw;:----------------------