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.

* 5. Reporting person name

* 6. Phone number of reporting person

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

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

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

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

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

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