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                                                                                                        UNITED PROVINCES OF AGRA AND OUDH                              31

VACCINATION FORM No. 3.

                                Statement showing vaccinations performed in the district during the month of—190

Number.

Name of
Vaccinator

Name of
Tahsíl
where
posted.

Primary vaccination.

Re-vaccination.

Increase or decrease in com-
parison with corresponding
month of the previous year.

Sex.

Caste.

Result.

Age of successful
case.

Sex.

Successful.

Total of successful
primary vaccinations
and re-vaccinations
for the present month.

Total of successful
primary vaccinations
and re-vaccinations
for the correspond-
ing month of the
previous year.

Increase.

Decrease.

Male.

Female.

Total.

Christians.

Muhammadans.

Hindus.

Other classes.

Total.

Successful.

Unsuccessful.

Absent.

Total.

Under one
year.

One and under
six years.

Six years and
upwards.

Total.

Male.

Female.

Total.

Total ...

                                                        NOTE.—This statement should be submitted to the District Superintendent of Vaccination within seven days after the expiry of the month.

Date—                                                                                                                                                                                                                Signature of Assistant Superintendent of Vaccination.

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