Influenza-Like Illness (ILI) Reporting Form

Name: Date:
School:
Home Address
Home Street:
City:       State:       Zip Code:
Resident Students
Residence Hall:            Room:
DOB:   Home Phone:    Cell Phone:
Email Address:
Gender:            Classification:

Individuals with any underlying health problems such as asthma, diabetes or cancer or any immune deficiency condition are urged to contact your health care provider as soon as possible.

Please indicate when you first noticed your symptom(s):

Please select all those symptoms that apply to you and describe in detail:

Comments:
Submitted by: