Influenza Information Notification Form

PUBLIC CHAPTER 687 requires the Department of Human

Services and the Department of Health to work together to

educate parents of children in child care agencies regarding the

importance of immunizing their children against influenza. The

Department of Human Services works with child care agencies to

ensure that this information is distributed annually to parents in

August or September.

I/We acknowledge that we have received information on the

importance of immunizing children against influenza.

__________________________________________________

Signature of Parent or Legal Guardian

Date

__________________________________________________

Signature of Parent or Legal Guardian

Date

___________________________________________________

Signature of Agency Representative

Date

HS – 3034 Revised 9-12-11

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Parent category: Medical