Aggregate Hospital

Form Approved

OMB No. 0920-0004

Exp. Date 6/30/2013

Aggregate Hospitalization and Death Reporting Activity Weekly Report Form

Reporting Jurisdiction
Date of Report (mm/dd/yyyy)

First Name
Last Name
Phone Number
Fax Number
Email

	Weekly number by age group (years)
Number of persons hospitalized with laboratory-confirmed influenza	0-4
	5-17
	18-49
	50-64
	65+
	Unknown
	TOTAL
Number of persons hospitalized with influenza and/or pneumonia syndrome	0-4
	5-17
	18-49
	50-64
	65+
	Unknown
	TOTAL
Number of persons who died from laboratory-confirmed influenza	0-4
	5-17
	18-49
	50-64
	65+
	Unknown
	TOTAL
Number of persons who died from influenza and/or pneumonia syndrome	0-4
	5-17
	18-49
	50-64
	65+
	Unknown
	TOTAL

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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).