Please use this form to report absenteeism when over 10%, and once it has fallen back under 10%. Contact Information School Name * Your Full Name * Your Email Address * Phone Number * Extension Absenteeism Information Is absenteeism OVER 10%? * Yes No Date of Absenteeism * Year201920202021 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Student Information Please enter 0 if there were no ill students. Number of Ill Students * Total Students in School * Grades of Ill Students Please select all applicable grades of ill students. JK SK 1 2 3 4 5 6 7 8 9 10 11 12 Entire School Staff Information Please enter 0 if there were no ill staff members. Number of Ill Staff * Total Staff in School * Symptoms Presenting Symptoms * Please select all applicable symptoms. If 'other' is selected, please specify in the field below. Nausea Vomiting Diarrhea Fever Cough Runny Nose Sore Throat Other Other Details Recent school activities or events Is food service offered on-site? * Yes No Please Submit this form to let us know absenteeism is now below 10%. Leave this field blank Submit
