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STAFF USE Clinic Site: Clinic Date: Verified by: 2017 INFLUENZA IMMUNIZATION CONSENT ADULTS AND CHILDREN 5 YEARS AND OLDER PATIENT INFORMATION (Please Print Clearly) First Name M.I. Last Gender MF
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What is adults and children 5?
Adults and children 5 is a form used to report information about adults and children under the age of 5.
Who is required to file adults and children 5?
Parents or guardians of children under the age of 5 are required to file adults and children 5.
How to fill out adults and children 5?
Adults and children 5 can be filled out online or submitted in person at the local government office.
What is the purpose of adults and children 5?
The purpose of adults and children 5 is to collect data on the population of adults and children under the age of 5 for demographic analysis and planning.
What information must be reported on adults and children 5?
Information such as names, ages, and addresses of adults and children under the age of 5 must be reported on adults and children 5.
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