[PROVISIONAL TRANSLATION FROM PERSIAN]

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

Islamic Republic of Iran

Ministry of Health and Medical Education

University of Medical Sciences and Health Services of Shiraz

Shiraz Department of Health, Hygiene and Medical Treatment Network (Martyrs of Val-fajr)

Electronic Form for Basic Data on Families

[In the official form questionnaire of Shiraz Department of Health, Hygiene and Medical Treatment Network, the religion of the individual -under the table for Particulars of Family, is enquired.]