H1N1 Influenza Information & Prevention

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Influenza-Like-Illness Reporting Form

Student Name:
Class Year:
Cell Phone:

Residence Hall and Room Number or Mile House Property

Symptoms

Date of symptom onset:

Health Care Evaluation

Were you evaluated by a health care provider for these symptoms? Yes No

If yes - Date of Evaluation:

Evaluated by the health center

Evaluated at the ER

Evaluated by a private physician

Other

Disposition

Because of influenza or influenza like illness, I plan to go...

Home

Stay isolated in my residence hall room

Other

Reminder
If you have influenza or influenza like illness, you are responsible for notifying your professors by email that you will be missing class. If the current H1N1 trend continues, most student absences will be approximately one week or less.

Release of this information:
In order to monitor influenza like activity at Muhlenberg College, the information contained in this Form will be communicated with Health Services, Dean of Students Office, Residential Services, and other appropriate parties in accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA).

Check here if you do not want this form released beyond your Health Center Treatment Record.