Copy of School Absentee Surveillance Survey

Thank you for participating in our school absentee surveillance efforts! Please fill out this survey daily. If you have any questions, contact Emily Leedy, MPH at 419-774-4773 or eleedy@richlandhealth.org.

*REMINDER: students who are out of school for reasons other than illness (ex. field trip, vacation, etc.) should NOT be counted as absent in this survey.

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* 1. School Name

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* 2. Reporting Date

Date

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* 3. Total Student Population

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* 4. Number of Students Called in Sick

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* 5. Number of Students Sent Home Sick

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* 6. Gastrointestinal Illness

Diarrhea

Food Poisoning

Stomach Flu

Vomiting

Other (please specify)

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* 7. Respiratory

Cold

Cough

Influenza (respiratory flu)

Sinus

Sore Throat

Other (please specify)

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* 8. Neurological

Headache/Migraine

Passed Out

Seizure

Stiff Neck

Other (please specify)

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* 9. Rash, Constitutional & General

Chicken Pox

Scabies

Fever

Muscle/Body Aches

Asthma/Allergies

Pink Eye

Unknown

Other (please specify)

Copy of School Absentee Surveillance Survey

Question Title

* 1. School Name

Question Title

* 2. Reporting Date

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* 3. Total Student Population

Question Title

* 4. Number of Students Called in Sick

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* 5. Number of Students Sent Home Sick

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* 6. Gastrointestinal Illness

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* 7. Respiratory

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* 8. Neurological

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* 9. Rash, Constitutional & General

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* 10. Comments: