US Outpatient Influenza like Illness Surveillance Networ

Form Approved
OMB No. 0920-0004

US Outpatient Influenza-like Illness
Surveillance Network (ILINet), Daily ILINet
Reports of Influenza-like Illness (ILI)
Daily Report for _____/_____/_____
ID Number

Check if
revised
report

Number of Patients with ILI
0-4 years

5-24 years

25-49 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).

50-64 yrs

>64 yrs.
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).