Ill. Admin. Code tit. 89, pt. 148, subpt. F, tbl. A
Current through Register Vol. 48, No. 52, December 27, 2024
Date ___________________
Initialed _________________
Patient Identification Number __________________
PATIENT'S NAME ________________________________________________________
LastFirstMiddle Initial
In questions 1 through 4 below, please circle one number or group of numbers:
1. | NUMBER OF PERSONS IN FAMILY | 1 | 2 | 3 | 4 | 5 | 6 or more |
2. | NUMBER OF CHILDREN | 1 | 2 | 3 | 4 | 5 or more | |
3. | AGE OF OLDEST CHILD IN YEARS | 0-5 | 6-15 | 16-17 | 18 and over | ||
4. | AGE OF HEAD OF HOUSEHOLD | Under 35 | 35-54 | 55-64 | 65 and over | ||
BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR= | __________ (see Table B) | ||||||
Ill. Admin. Code tit. 89, pt. 148, subpt. F, tbl. A