1. WEEKLY School Absenteeism Report

***Please use this form to report WEEKLY to the Health Department's Communicable Disease Programs about the number of students absent. PLEASE SUBMIT BY 4:30PM on Monday following the week you are reporting data for.

Reporting person name

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* 5. Reporting person name

Phone number of reporting person

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* 6. Phone number of reporting person

Total number of ABSENCES this week to illness.

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* 7. Total number of ABSENCES this week to illness.

Total number of ABSENCES DUE TO ILLNESS this week.

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* 8. Total number of ABSENCES DUE TO ILLNESS this week.

Number of days school was in session this week:

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

AVERAGE DAILY student enrollment for this week. (Only answer if enrollment has changed by more than 10 since last week)

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* 10. AVERAGE DAILY student enrollment for this week. (Only answer if enrollment has changed by more than 10 since last week)

OPTIONAL: How many absences were due to...

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* 11. OPTIONAL: How many absences were due to...

Comments: Please include any additional information. Call the health department for reportable disease information.

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* 12. Comments: Please include any additional information. Call the health department for reportable disease information.

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