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DEPARTMENT OF HUMAN SERVICES

CITIZENS PLAZA BUILDING

400 DEADERICK STREET NASHVILLE, TN  37243-1403

TELEPHONE:  615-313-4700  FAX:  615-741-4165

TTY:  1-800-270-1349

WWW.state.tn.us/humanserv/

PHIL BREDESEN-GOVERNOR     VIRGINIA T. LODGE-COMMISSIONER


INFLUENZA INFORMATION NOTIFICATION

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.


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Signature of Parent or Legal Guardian                                               Date

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Signature of Parent or Legal Guardian                                                Date

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Signature of Agency Representative                                                   Date