Clusters of Illness
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1. School Report Form
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1
. Date of Report (format 03/02/2010):
Date of Report (format 03/02/2010):
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. School District:
School District:
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3
. School Name:
School Name:
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4
. Student Enrollment:
Student Enrollment:
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5
. Number of Students Normally Absent:
Number of Students Normally Absent:
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6
. Person Sending Report:
Person Sending Report:
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. Telephone #:
Telephone #:
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. Email:
Email:
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. Type of illness being reported:
***Please report any reportable diseases (e.g., pertussis, meningitis) to Epidemiology as required using methods and time frames specified on the reportable disease list at www.ochealthinfo.com/epi***
Type of illness being reported: ***Please report any reportable diseases (e.g., pertussis, meningitis) to Epidemiology as required using methods and time frames specified on the reportable disease list at www.ochealthinfo.com/epi***
Respiratory Illness (e.g. fever, cough, and/or sore throat)
GI Illness (e.g. diarrhea and/or vomiting)
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. Common symptoms reported:
Common symptoms reported:
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