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 (a) (b) (c) (d) (e) (f) Women Unknown Served Number Total Title XIX Title XXI Private/ None % (g) Served Served % % Other % % Women 25+ 25-29 30-34 35-44 45-54 55-64 65+ Table 5 (a) (b) (c) (d) (e) (f) Other Unknown Number Total Title XIX Title XXI Private/ None % (g) Served Served % % Other % % Men 25+ TOTAL SERVED: ________________ INSTRUCTIONS FOR THE COMPLETION OF FORM 5 NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED) By Type of Individual and Source of Primary Insurance Coverage For Projects Providing Direct Health Care, Enabling or Population-based Services Enter data into all required (unshaded) data cells. If an actual number is not available, make an estimate. Please explain all estimates, in a note.
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 NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED) By Type of Individual and Source of Primary Insurance Coverage For Projects Providing Direct Health Care, Enabling or Population-based Services Enter data into all required (unshaded) data cells. If an actual number is not available, make an estimate. Please explain all estimates, in a note.
T72.2%20-%20DGIS%20Forms%20and%20PMs.docx