356 CLEAN MILK 



"W. C. in yard Privy Location _ 



General sanitary condition of residence 



OCCUPATION. 



Place from to _ 



Other cases 



WATER WITHIN 30 DAYS PRIOR. 



Solely Principally 



Occasionally 



FOOD WITHIN 30 DAYS PRIOR. 



Where taken 



Milk (how used) From 



Boiled ? Pasteurized ? .. 



Ice cream? "Where? 



Uncooked fruits and vegetables 



Shellfish 



CONTACTS. 



Association 30 days prior with patients in febrile stage 



" with suspected cases 



with persons who have had typhoid within 6 months 



1 year 



2 years 



3 years 



4 years 



5 years 



Association 30 days prior with persons in contact with patients in febrile 



stage 



Treatment of stools and urine of patients 



Other precautions 



Remarks 



Summary 



Signature _ 



