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        Sentinel Provider Reports of Influenza-Like Illness (ILI)                   

 

       
       

  Yes        
           
           
Number of Patients with ILI:    

Influenza-Like Illness

Fever (>100oF {37.8oC} oral or equivalent)      AND                                                                          Cough and/or sore throat                                                 (in the absence of a known cause)
   
 
 
> 64 Years (Older Adults)                                                              

Total Number of Patients Seen for Any Reason  

       
                                                       

These cells cannot be left blank!!

    

Name of Person Submitting Report   

       

 

  
                          
     
     
     
     
     
     
                 

 

 

 

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