Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

School Syndromic Surveillance Weekly Reporting - Epidemiology

  1. Sympton
  2. Number of cases this week only
    Enter "0" if you have no cases
  3. Fever/fever-related symptoms
    Oral temperature >/= 100 degrees F
  4. Diarrhea
  5. Vomiting
  6. Respiratory Illness
    Congestion, runny nose, cough, wheeze, stuffy nose, respiratory allergies
  7. Rash
    Chicken pox, scabies, hives, poison ivy
  8. Sore throat
  9. Headache
  10. Asthma attacks and asthma prevention
    Preventative puffs
  11. Stomach ache
  12. Leave This Blank:

  13. This field is not part of the form submission.