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* 1. Date of Report (format 03/02/2010):

Date / Time (format 03/02/2010)
Date of first illness onset (format 03/02/2010)

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* 2. School Name and District

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* 3. Number of Students enrolled in school and classroom

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* 4. Number of Students Normally Absent in classroom(s)

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* 5. Reporter Information

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* 6. 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***

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* 7. Common symptoms reported

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* 8. Cluster(s) of illness (20% of classroom/group ill with similar illness, minimum of 5 ill) is/are located in:

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* 9. Group Details

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* 10. Comments

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