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Date: / NJ IIS# CUMBERLAND COUNTRY HEALTH DEPARTMENT (CCD) 309 Buck Street MILLVILLE, NJ 08332, TEL: 856-327-7602 2013-2014 Influenza Vaccine Consent Form / Report #: Child Health Dept. Section 1:

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3. Take your time to carefully read each question and provide accurate and honest answers. It is important to be truthful in order to provide the most accurate information for evaluation or screening purposes.
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