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Sample List for FAMILY PLANNING Observation<br />

Date<br />

2 0 1<br />

DAY MONTH YEAR FACILITY #<br />

USE THIS FORM TO LIST FP CLIENTS SELECTED FOR FP OBSERVATION FOR PROVIDER #2<br />

NAME/INITIALS<br />

FIRST VISIT<br />

FOLLOW-UP<br />

226<br />

227<br />

228<br />

229<br />

230<br />

231<br />

232<br />

233<br />

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235<br />

236<br />

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350 • Appendix C

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