1 to 25 years 12-24 months 25 months- 4 years 5-9 10-14 15-19 20-24 Table 3 CSHCN (a) (b) (c) (d) (e) (f) (g) Infants, Number Total Title XIX Title XXI Private/ None Unknown Children and Served Served % % Other % % % Youth Served Infants <1 yr Children and Youth 1 to 25 years 12-24 months 25 months- 4 years 5-9 10-14 15-19 20-24 Table 4 Women (a) (b) (c) (d) (e) (f) Unknown Served Number Total Title XIX Title XXI Private/ None % Served Served % % Other % % (g) Women 25+ 25-29 30-34 35-44 45-54 55-64 65+ Table 5 Other (a) (b) (c) (d) (e) (f) Unknown Number Total Title XIX Title XXI Private/ None % Served Served % % Other % % (g) Men 25+ TOTAL SERVED: ________________ INSTRUCTIONS FOR THE COMPLETION OF FORM 5
1 to 25 years 12-24 months 25 months- 4 years 5-9 10-14 15-19 20-24 Table 3 CSHCN Infants, Children and Youth Served (a) Number Served (b) Total Served (c) Title XIX % (d) Title XXI % (e) Private/ Other % (f) None % (g) Unknown % Infants <1 yr Children and Youth 1 to 25 years 12-24 months 25 months- 4 years 5-9 10-14 15-19 20-24 Table 4 Women Served (a) Number Served (b) Total Served (c) Title XIX % (d) Title XXI % (e) Private/ Other % (f) None % Unknown % (g) Women 25+ 25-29 30-34 35-44 45-54 55-64 65+ Table 5 Other (a) Number Served (b) Total Served (c) Title XIX % (d) Title XXI % (e) Private/ Other % (f) None % Unknown % (g) Men 25+ TOTAL SERVED: ________________ INSTRUCTIONS FOR THE COMPLETION OF FORM 5