School Communicable Disease Reporting Form

Michigan School Building Weekly Report of Communicable Disease to Local Health Department


	According to Public Act 368, of 1978 as amended, the local health department shall be notified immediately of the occurrence of communicable disease (especially rash-like illness with fever).

In addition to immediate notification of serious/rare illnesses by telephone, please submit all occurrences on this form.

ONLINE REPORTING INSTRUCTIONS: Please record all appropriate information and submit each MONDAY by 11AM EVEN IF THERE ARE NO DISEASES TO REPORT. Click "submit data" at the bottom of the page to send it to the health department.

*Highlighted fields are required*

WEEK ENDING: Friday,
DISTRICT:	Type:	School:

CURRENT SCHOOL ENROLLMENT
TOTAL NUMBER OF CHILDREN ABSENT THIS WEEK

AGGREGATE CASE COUNT REPORTING*: Please record total number of cases for flu-like illness and stomach virus.

	NUMBER OF CASES	DEFINITION
FLU-LIKE ILLNESS (APPARENT INFLUENZA)		FLU-LIKE ILLNESS is fever and any of the following symptoms: Sore throat, cough, generalized aching in the back and limb muscles. *Vomiting and diarrhea alone are NOT indicators of influenza
STOMACH VIRUS		STOMACH VIRUS is diarrhea and/or vomiting for 24 to 48 hours.
STREP THROAT		STREP THROAT is often doctor diagnosed and is characterized by a severe sore throat with fever and headache

*NOTE: The health department will no longer be collecting numbers of head lice cases or pink eye (conjunctivitis). Contact School Health Services at (810)257-3591 for more information regarding head lice or pink eye in schools.

INDIVIDUAL DISEASE REPORTING: Use the following lines to complete information for ALL INDIVIDUALS WITH CONFIRMED OR SUSPECTED CASES of communicable diseases below, including chickenpox.

Serious/rare illnesses: In addition to reporting on this form, call the health department at (810)257-1017 IMMEDIATELY to report: measles, mumps, rubella, pertussis, Haemophilus influenza type B, meningitis, encephalitis, hepatitis, tuberculosis, or any other serious communicable disease occurrence.

*If there are no diseases to report or if the school is closed due to illness please check the appropriate box below.

DISEASE	DATE 1^ST ABSENT	FIRST NAME	LAST NAME	DATE OF BIRTH	GRADE	STUDENT PHONE	STUDENT ADDRESS	PARENT NAME	DISEASE IDENTIFIED BY

ADDITIONAL COMMENTS:

PLEASE CHECK IF:

NO DISEASES TO REPORT THIS WEEK

SCHOOL CLOSED DUE TO ILLNESSES

SUBMITTED BY:

PHONE NUMBER:

TODAY'S DATE:

For more information, contact Fatema Mamou at the Genesee County Health Department at 810-768-7971 or fmamou@gchd.us.

Last update: 09/20/2010