Form CDC 55.20 CDC 55.20 US Outpatient Influenza-like Illness Surveillance Networ

Form Approved
OMB No. 0920-0004

US Outpatient Influenza-like Illness
Surveillance Network (ILINet) Weekly,
(CDC 55.20)
Report for the 7-day period ending

_____/_____/_____
ID Number

Check if
revised
report

Number of Patients with ILI
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.

Note:
There is no requirement for a positive
influenza test (i.e. rapid antigen test) when
determining the number of patients with ILI.

Total 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 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).