WEEKLY School Absenteeism

1. WEEKLY School Absenteeism Report

THANK YOU FOR ANOTHER YEAR OF GREAT REPORTING! PLEASE CONTINUE TO REPORT DATA UNTIL SUMMER BREAK! SEE YOU NEXT YEAR!
***Please use this form to report WEEKLY to the Health Department's Communicable Disease Programs about the number of students absent. PLEASE SUBMIT BY 3:30PM on Friday of the week you are reporting data for.

*
1. SCHOOL NAME

SCHOOL NAME

If your school is NOT in drop-down list, or you would like the name displayed differently above, please choose "school not listed" and enter school name here.

*
2. CITY

CITY

*
3. School district

School district

*
4. DATE

	MM		DD		YYYY
Today	DATE Today Month	/	Day	/	Year

*
5. Reporting person name

Reporting person name

*
6. Phone number of reporting person

Phone number of reporting person

*
7. Total number of ABSENCES this week.

Total number of ABSENCES this week. Number absent

*
8. Number of days school was in session this week:

Number of days school was in session this week:

*
9. AVERAGE DAILY student enrollment for this week.

AVERAGE DAILY student enrollment for this week. Number enrolled

10. Comments:Please summarize morbidity information.Call the health department for reportable disease information.

Comments:Please summarize morbidity information.Call the health department for reportable disease information.

WEEKLY School Absenteeism

1. WEEKLY School Absenteeism Report

*1. SCHOOL NAME

*2. CITY

*3. School district

*4. DATE

*5. Reporting person name

*6. Phone number of reporting person

*7. Total number of ABSENCES this week.

*8. Number of days school was in session this week:

*9. AVERAGE DAILY student enrollment for this week.