Clusters of Illness

1. School Report Form

 
*
1. Date of Report (format 03/02/2010):
2. School District:
*
3. School Name:
*
4. Student Enrollment:
*
5. Number of Students Normally Absent:
*
6. Person Sending Report:
*
7. Telephone #:
*
8. Email:
*
9. 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***
*
10. Common symptoms reported:
Powered by SurveyMonkey
Check out our sample surveys and create your own now!