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
- 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.
Weekly Report
Daily Report When Requested
* is required field
:
DISTRICT:
Anchor Bay School District
Armada Area Schools
Center Line Public Schools
Charter
Chippewa Valley Schools
Choose One
Clintondale Comm Schools
Eastpointe Community Schools
Fitzgerald Public Schools
Fraser Public Schools
Head Start
L'Anse Creuse Public Schools
Lake Shore Public Schools
Lakeview Public Schools
Macomb Intermediate School Dst
Mt Clemens Community Sch Dist
New Haven Community Schools
Private
Private Chain
Private Parochial
Richmond Community Schools
Romeo Community Schools
Roseville Community Schools
South Lake Schools
Utica Community Schools
Van Dyke Public Schools
Warren Consolidated Schools
Warren Woods Public Schools
*
SCHOOL:
Choose One
*
K12
PRESCHOOL/DAYCARE
*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.
Disease
Vaccine Dates (mm/dd/yyyy)
Date 1st Absent (mm/dd/yyyy)
First Name
Last Name
Date of Birth (mm/dd/yyyy)
Grade
Student Phone(123-444-5555)
Student Address
Parent Name
Disease Identified By
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
Choose One
Chickenpox - Varicella Dates
COVID-19
Fifth Disease - MMR Dates
Hand, Foot, and Mouth Disease
Hepatitis A
Hepatitis B
Hepatitis C
Measles - MMR Dates
Meningitis
Mononucleosis, Infectious
Mumps - MMR Dates
Other - Add in comments
Pertussis - DTap Dates
Rash - MMR Dates
Rubella - MMR Date
Scabies
Scarlet Fever - MMR Dates
-
DC
Pre
K
1
2
3
4
5
6
7
8
9
10
11
12
+
Choose one
Doctor
Parent/Guardian
Other
ADDITIONAL COMMENTS:
PLEASE CHECK IF:
NO DISEASES TO REPORT
SCHOOL CLOSED DUE TO ILLNESSES
SUBMITTED BY:
PHONE NUMBER:
Please enter phone number in format of 123-444-5555
TODAY'S DATE:
