Aggregate Hospital

National Disease Surveillance Program - II. Disease Summaries

AHDRA Form

Att S_Aggregate Hospitalization and Death Reporting Activity Weekly Report Form

OMB: 0920-0004

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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).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleINFLUENZA AGGREGATE CASE REPORT SUMMARY
Authordvk3
File Modified0000-00-00
File Created2021-01-27

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