MACOMB COUNTY HEALTH DEPARTMENT
MICHIGAN SCHOOL BUILDING WEEKLY REPORT OF COMMUNICABLE DISEASES TO THE LOCAL HEALTH DEPARTMENT

  According to Public Act 368, of 1978 as amended, the local health department shall be notified immediately of the occurrence of communicable disease (especially rash-like illness with fever).  

In addition to immediate notification of serious/rare illnesses by telephone, please submit all occurrences on this form.
ONLINE REPORTING INSTRUCTIONS:  Please record all appropriate information and submit by 5:00 PM Friday - EVEN IF THERE ARE NO DISEASES TO REPORT. Please check appropriate check box.  Click "Submit Data" at the bottom of the page to send it to the Health Department.
* is required field
WEEK ENDING: Friday,:      
DISTRICT: *   SCHOOL: *
 
*If there are no diseases to report or if the school is closed due to illness please check the appropriate box below.
 
CURRENT SCHOOL ENROLLMENT *
AGGREGATE CASE COUNT REPORTING:  Please record total number for the following diseases
  NUMBER OF CASES DEFINITION
FLU-LIKE ILLNESS
(APPEARENT INFLUENZA)

FLU-LIKE ILLNESS is fever and any of the following symptoms: sore throat, cough, generalized aching in the back and limb muscles.
*vomiting and diarrhea alone are NOT indicators of influenza
STOMACH VIRUS
STOMACH VIRUS is diarrhea and/or vomiting for 24 to 48 hours. It is often caused by Norovirus
STREP THROAT
STREP THROAT is often doctor diagnosed and is characterized by a severe sore throat with fever and headache
PINK EYE
PINK EYE an inflammation or infection of the transparent membrane that lines the eyelid and part of the eyeball which causes red, swollen eyes and lid with pain, itching and drainage.
HEAD LICE  (PEDICULOSIS)
HEAD LOUSE is a tiny, wingless parasitic insect that can be found on the head and causes itchiness of the scalp, and sores from itching.
COVID-19  STAFF
COVID-19 - Test positive for COVID-19 (PCR or antigen test)
COVID-19  STUDENTS
COVID-19 - Test positive for COVID-19 (PCR or antigen test)
 
INDIVIDUAL DISEASE REPORTING: Use the following lines to complete information for ALL INDIVIDUALS WITH CONFIRMED OR SUSPECTED CASES
of communicable diseases below,
including chickenpox.   

Serious/rare illnesses: In addition to reporting on this form, call the health department at (586)783-8190 IMMEDIATELY to report: measles,
mumps, rubella, pertussis, haemophilus influenza type b, meningitis, encephalitis, hepatitis, tuberculosis, or any other serious communicable disease occurrence.
DiseaseVaccine Dates (mm/dd/yyyy)Date 1st Absent (mm/dd/yyyy)First NameLast NameDate of Birth (mm/dd/yyyy)GradeStudent Phone(123-444-5555)Student AddressParent NameDisease Identified By
 
 
 
 
 
 
 
 
 
 
 
ADDITIONAL COMMENTS:
PLEASE CHECK IF:

THIS WEEK

SUBMITTED BY:    
PHONE NUMBER:      Please enter phone number in format of 123-444-5555
TODAY'S DATE: