School Absenteeism Report Form

School Name:
Grades:
Address:
City:
State:
Zip:
County:	Please select a county Adams Barnes Benson Billings Bottineau Bowman Burke Burleigh Cass Cavalier Dickey Divide Dunn Eddy Emmons Foster Golden Valley Grand forks Grant Griggs Hettinger Kidder La Moure Logan McIntosh McHenry McKenzie McLean Mercer Morton Mountrail Nelson Oliver Pembina Pierce Ramsey Ransom Renville Richland Rolette Sargent Sheridan Sioux Slope Stark Steele Stutsman Towner Traill Walsh Ward Wells Williams
Name of Reporter:
Phone Number:
Email:
Date of Absenteeism:
Number of students absent due to illness:
	Of these, how many due to influenza-like illness (if known):
Total number of students enrolled at time of the outbreak:
Number of staff absent due to illness:
Total number of staff:
Please indicate the five most common symptoms associated with this outbreak: Coryza (runny nose) Fever Stomach ache Chills Myalgia (body ache) Cough Vomiting Rash Sorethroat Headache Diarrhea Earache
Comments:
Would you like the NDDoH to contact you regarding this report?	YesNo