Influenza-like illness Reporting

Form Approved

OMB No. 0920-0004

Exp. Date 6/30/2013

ILINet Reports of Influenza-like Illness (ILI)

***DAILY**** REPORT FORM

Influenza Surveillance Season

Check if revised report

D aily Report for _____/_____/_____

Number of Patients with ILI

ID Number

0

-4 years

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).

5-24 years

25-49 years

50-64 yrs

>

64 yrs.

T otal Number of Patients Seen for Any Reason

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

DO NOT LEAVE THIS 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 15 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).