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:

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