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Sandusky County Influenza Surveillance for Physicians and Urgent Cares
Please complete and submit this form weekly during flu season
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* Indicates required question
The influenza reporting period is 12:00AM
Sunday
through 11:59PM
Saturday
. Please complete this survey no later than Monday by the end of the business day.
Name of Reporting Facility or Physician
*
Your answer
Report Week
Start Date
(Sunday):
MM
/
DD
/
YYYY
Report Week
End Date
(Saturday):
MM
/
DD
/
YYYY
Total number of patients
seen for influenza like illness:
( ILI= Fever greater or equal to 100F AND Cough, AND/OR Sore Throat)
Your answer
Total number of Positive
influenza A
(rapid-or send-out):
Your answer
Total number of Positive
influenza B
(rapid-or send-out):
Your answer
Total number of
untyped positive influenza:
Your answer
Additional Notes/Information that might be relevant to this reporting week:
Your answer
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