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a~ <br />32, WHAT WAS TH>/ NAM); AND ADDRESS OF <br />THI/ M1;DICAL FACILITY THAT PROVID)iD <br />TRIiATM1JNT? <br />ADDRESS <br />BUILDING NUMBER AND STREET NAME <br />CITY <br />STATE <br />ZIP <br />3.3. Medical Release Information <br />It is possible that further investigation will be needed in this study. If needed, would you be willing to <br />provide copies or allow the Orange County Health Department to obtain copies of your medical files for <br />review? ^ YES ^ NO <br />In order to do this, you will have to sign a medical release statement giving the Orange County Health <br />Department permission to obtain and review your files. Would you be willing to sign a medical release <br />statement? ^ YES ^ NO <br />34. PL)JAST; CONFIRM YOUR HOM7; NUMBTJR <br />INCAS); I N>;)/D TO CALL BALI{ <br />###-##1#-##t#f{ <br />35. IS TH1;RT; ANOTHER PHON>; NUMBER? <br />##i#-###-###'# <br />36. WHAT'S THL B)J5T TIM1J TO CALL YOU? <br />Work History <br />37. WHAT IS YOUR <br />«P1;RSON'S» <br />CURRENT JOB OR <br />OCCUPATION? <br />38. );MPLOYF,R & <br />LOCATION: <br />39. TYP>/ OF <br />WORI{: <br />40. TIM>/ WORI{1;D <br />IN THIS JOB: <br />^ RETIRED ^UNEMPLOYED <br />START DATE <br />END DATE <br />Page 24 of 47 <br />