Influenza-Like Illness (ILI) Surveillance
This report is for the week ending... *
Choose the Saturday prior to the date report is submitted:
MM
/
DD
/
YYYY
What facility is reporting? *
Name of site:
ILI is defined as a fever over 100°F and cough and/or sore throat in the absence of another diagnosis. *
How many ILI this week?
Your answer
Were there any influenza-related pediatric (under 18 years of age) deaths in your facility this week? *
(All pediatric influenza-related mortality should be reported via fax or telephone to the Epidemiologist within 1 working day.)
Laboratory test results
Only complete if you have confirmed laboratory test results
# Flu A:
How many positive Flu A this week?
Your answer
# Flu B:
How many positive Flu B this week?
Your answer
# Flu Non-differentiated:
(Not differentiated means it was Flu positive but the test cannot distinguish which flu type)
Your answer
Email address *
Your answer
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