1. School Report Form

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

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* 2. School District:

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* 3. School Name:

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* 4. Student Enrollment:

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* 5. Number of Students Normally Absent:

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* 6. Person Sending Report:

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* 7. Telephone #:

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* 8. Email:

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* 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***

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* 10. Common symptoms reported:

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