Contact Information School/Childcare Center Name Your Full Name Your Email Address Your Title/Position Phone Number Extension Absenteeism Information Is absenteeism ≥ 20% or is there an illness concern within a cluster? Yes No Date of Absenteeism Student Information Grades/Rooms of Ill Students Infant Toddler Preschool Before/After School JK SK 1 2 3 4 5 6 7 8 9 10 11 12 Entire School/Childcare Centre Other Other (please specify) Staff Information Symptoms Presenting Symptoms Nausea Vomiting Diarrhea Fever Cough Runny Nose Sore Throat Other Other Details Additional Details Recent school/centre activities or events Is food service offered on-site? Yes No No further action needed Please Submit this form to let us know absenteeism is now below 10%. Submit
