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2012-2013 School Absenteeism Survey

*Only illness absentees are to be reported, not absentees due to sports trips, school activity trips, dental appointment, vacations, etc. A student is counted for each day absent. If a student is absent 3 days in a week he/she would be counted 3 times.

If you have questions please do not hesitate to contact Vickie Horan, 773-3737 or 800-592-1861.

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* 1. School week for which you are reporting:

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* 2. What is your School District?

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* 3. What is the name of your school?

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* 4. County your school is physically located:

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* 5. School point of contact: (Name)

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* 6. Phone number for Point of Contact:

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* 7. Number of students enrolled: (please enter a number)

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* 8. Number of student absent days due to illness: (please enter a number)

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* 9. Number of staff: (If no data enter 0)

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* 10. Number of staff absent days due to illness: (If no data enter 0)

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* 11. Number of scheduled school days this week:

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* 12. Was school closed any days this week?

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* 13. If yes, why was the school closed? (i.e. snow day, in-service, vacation, illness, etc):

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* 14. If yes, how many days was your school closed? (Please enter a number)

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