MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

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 illnesses with fever).
In addition to immediate notification by telephone, please include all occurrences on this form and fax or mail to your local health department.

INSTRUCTIONS

A: Record appropriate information in Sections 1, 2, 3, 4 & 5.

B: Submit this form EACH FRIDAY to the Huron County Health Department EVEN IF THERE ARE NO DISEASES TO REPORT.

C. Add additional sheets as necessary.

1 Week Ending:

District:
School, Preschool or Day Care:
Current School Enrollment:

2 List all confirmed or suspected cases of communicable diseases, including but not limited to: Measles, Rubella (German measles), Mumps, Hepatitis, Scarlet Fever, Strep Throat, Scabies, Pertussis (Whooping Cough), Haemophilus influenzae type b, Encephalitis, Meningitis, Tuberculosis, Chickenpox (Varicella), Salmonellosis, Shiga toxin producing E. coli, Campylobacteriosis and Shigellosis.

DISEASE	DATE FIRST ABSENT	CHILD'S NAME LAST, FIRST	AGE / SEX	GRADE	ADDRESS/CITY/ZIP	PHONE NUMBER(S)	DIAGNOSED BY: (Dr., parent, teacher, etc)

3 Indicate here (by number only) suspected or confirmed cases of:
Apparent Flu*:
Pediculosis (Head Lice):
Gastrointestinal Illness (diarrhea and/or vomiting for 24-48 hours):
*Count as APPARENT FLU case any child with pneumonia or fever and any of the following symptoms: sore throat, cough, generalized aching in the back or limb muscles. Please report apparent influenza by total numbers only. Vomiting and diarrhea alone are not indications of influenza.

4 Place an X here if:
NO DISEASES TO REPORT
SCHOOL CLOSED DUE TO DISEASE

5
SUBMITTED BY:
TELEPHONE #:

DATE: