Influenza sentinel hospital surveillance 2014-15

1. Facility name:
2. County:
3. Reporter:
4. Email:
5. Reporting MMWR week ending schedule:
(Each reporting week is defined Sunday though Saturday. The date listed below is the last day for the reporting week. Choose the week you are reporting for based on the last day of that reporting week. For example, if you are reporting for the week of September 7-September 13, 2014, choose September 13, 2014.)
Reporting week
6. Total number of patients hospitalized for influenza-associated conditions
7. Total number of inpatients by age group (provide total if you can not break down by age group)