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SYNDROMIC CATEGORIES
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TOTALS
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Influenza-like illness
Malaise, headache, fever, cough and sore throat, in the absence of known cause. |
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Hemorrhagic disease
Bleeding from skin or mucus membrane surfaces or reddish or purplish spots or discolorations on the skin or mucus membrane surfaces. |
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Gastrointestinal illness
Diarrhea, vomiting, abdominal pain or cramps, with or without fever. |
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Neurologic illness
Headache, sensitivity to light, confusion, convulsions, double/blurred vision, drooping eyelid(s), muscle twitching, difficulty talking/swallowing, weakness or paralysis. |
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Rash illness
Rashes with or without fever (including chicken pox, exanthema, dermatitis, erythema). |
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Fever illness
Fever of unknown origin (such as acute febrile illness, viral syndrome, sepsis, suspect infection). |
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Respiratory illness (other than influenza-like illnesses)
Cough, sore throat, trouble breathing, pneumonia and other respiratory conditions, with or without fever. Please do not enter influenza-like illness here. |
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Chemical exposure
Chemical exposure differs from the others in that the suspect agent is not biological and onset is sudden (within 60 minutes, often within 15 minutes or less).
Please list any chemicals or other agents that may have been involved in the reported exposure(s) in the other information section at the bottom of this form.
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NON-SYNDROMIC CATEGORIES
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TOTALS
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| Census of employees, students, etc. that should be at the location or if counting clinic visits, enter total number of all patients seen (including ER visits, urgent care visits, admissions, etc.).
*THIS NUMBER IS REQUIRED AND CRITICAL. It must be greater than zero and greater than the sum of the numbers above. Approximation is OK as long as something is entered. This number is the denominator for evaluating rates of absenteeism and illness.
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Required*
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| School/Workplace absenteeism |
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| Deaths |
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