0920-0004 Influenza-Like Illness (Oct-May) 55.20

FORM APPROVED

OMB NO. 0920-0004

SENTINEL PROVIDER REPORTS

OF INFLUENZA-LIKE ILLNESS (ILI)

2006-2007 Influenza Surveillance

Check if

Revised Report

Report for the 7-day period ending ___/___/___

ID Number (Period ends Saturday at midnight)

Number of Patients with ILI

0 -4 yrs.

(Pre-school)

Influenza-like Illness

Fever (100^ F [37.8^ C], oral or equivalent)

-AND -

cough and/or sore throat

(in the absence of a known cause).

24. yrs.

(School age)

25-64 yrs.

(Adults)

>64 yrs.

(Older Adults)

Total Number of Patients Seen For Any Reason

(Total of ILI + Non-ILI cases for all age groups combined)

DO NOT LEAVE BLANK.

WITHOUT THIS NUMBER, THE REPORT CANNOT BE USED.

FAX THIS FORM TO 1-888-232-1322

(NO COVER SHEET IS REQUIRED)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 55.20

REV. 6/06