Interview Subject (Select one): 1. State of Residence: 2. Phone: 3. Phone #5 (Enter Phone # 5 from the Subject List): 4. Interviewer's Address, City, State, Zip & Country: 25. Personal Attendants/Visitors: 26. Personal Attendants/Visitors Name: 27. Personal Attendants/Visitors Phone Number: 28. Personal Attendant/Visitors Email: 27. Interviewer's Occupation 1. Medical/Pharmacist: 2. Businessman: 3. Lawyer: 4. Other: Initial/Baseline 26. Personal Attendant/Visitor Name & Place of Employment 27. Interviewer's Age: 28. Interviewer's Sex: 1. Male: 2. Female: 3. Age (at interview): 29. Residence Telephone and Zip Code: 30. Interviewer's Occupation: (Select one): 31. Medical/Pharmacist: Select One: 2. Pharmacist: 3. Medical Physician: 4. Chiropractic Physician: 5. Dietitian: 6. Osteopath: 7. Orthopedic Surgeon: 8. Ophthalmologist: 9. Other: 31. Interviewer's Sex (Select one): 32. Interviewer's Age (Enter Interviewer's Age from question 31): 32. Interviewer's Ethnicity: 33. Interviewer's Sexual Orientation (Select one): 1. Straight: 2. Gay: 3. Bisexual: Select One: 34. Interviewer's Home Address and Zip Code (Select one): 34. Interviewer's Sex (Male or Female, or neither): 1. Male: 2. Female: 4. Ethnicity (Select one): 1. White: 2. Black: 3. Hispanic: 4. Other: 1. Interviewer's Height (in): (in) 35. Interviewer's Weight (in lbs.): 36. Interviewer's Gender (M or F, or both) (Select one): 1. Male: 2. Female: 3. Interviewer's Age (at interview): (at): 36. Interviewer's Blood Sample T-Cell Count (Enter T-Cell Count from the box below and click “Submit”): 37. Interviewer's Physical Exam Results (for the body type listed in question 11): 38. Interviewer's Personal Attendant/Visitor Name (From Box above) 39.
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HISTORY AND REPORT OF OM SEP EXAMINATION PART 1 (This form is subject to the Privacy Act Statement of 1974) 1. LAST Name, First Name, Middle Initial: 2. Grade/Rate/Rank: 3. SSN: 5. Home Address (apt×,
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