1. H1N1/Swine Flu Reporting Form

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This information is to inform the Office of the Dean of Students of your illness. It is the responsibility of the student to contact faculty members regarding missed classes. Students with flu-like symptoms should isolate themselves.

1. Student Name:

Student Name:

2. TUId Number:

TUId Number:

3. Student Contact Information (provide local address):

Student Contact Information (provide local address): Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:
Phone Number: