案由：_______________________________________________________
    调查时间：___________________________________________________
    调查地点：___________________________________________________
    调查人：_________________________   记录人：_________________
    被调查人：________  年龄______  性别_____  电话号码：________
    工作单位：___________________________________________________
    住址：_______________________________________________________

    问：__________________________________________________________
    答

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    答：     

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    问：__________________________________________________________
    答：    

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