ILI School Outbreak and Absenteeism Report Form

School Name:  
Grades:  
Address:  
City:  
State:  
Zip:  
County:    
Name of Reporter:  
Phone Number:  
Email:  
     
Date of Absenteeism:  
     
Number of students absent due to illness:    
  Of these, how many due to influenza-like illness (if known):  
     
Total number of students enrolled at time of the outbreak:    
     
Number of staff absent due to illness:    
     
Total number of staff:    
     
Please indicate the five most common symptoms associated with this outbreak:

Comments:
     
Would you like the NDDoH to contact you regarding this report?