4-35. EMERGENCY ADDRESSEE
a. Source of data. Admission intervew. (Items 24, 27, and 29, ITRCS).
b. Enter information relating to emergency addressee. Leave blank for CRO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
JOHN R. DALLAS/FATHER
ADDRESS OF EMERGENCY ADDRESSEE (Include Zip Code)
222 PRUNE STREET, FLINT MI 48504
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
4-36. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY (MTF)
a. Source of data. Self-explanatory (your MTF).
b. Enter the name and location of the reporting MTF.