School Building Weekly Report of Communicable Disease

Michigan School Building Weekly Report of Communicable Disease

According to the Public Act 368 of 1978 as amended, THE LOCAL HEALTH DEPARTMENT SHALL BE NOTIFIED WITHIN 24 HOURS OF THE OCCURRENCE OF COMMUNICABLE DISEASE (ESPECIALLY RASH-LIKE ILLNESSES WITH FEVER). In addition to immediate notification by telephone (517) 768-1662, please include all occurrences on this form. Guidance for managing communicable diseases in schools can be found here.
REPORT WEEKLY, EVEN IF THERE ARE NO DISEASES TO REPORT.

1. Please provide the following information.

Week Ending (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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School/Preschool/Child care
*“If you don’t see your school listed above, please
contact Jana at jsnider@mijackson.org. *This question is required.

Please Specify Name *This question is required.

District
*Select "Day care/Preschool/Child care" if reporting as a day care, preschool, or child care. *This question is required.

Please Specify District *This question is required.

Date (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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Submitted by

Title

Telephone #

Current Enrollment

Please check if either apply.

NO DISEASES TO REPORT
SCHOOL CLOSED THIS WEEK DUE TO EXCESSIVE ABSENCES

2. Indicate the NUMBER of cases of each illness. These DO NOT need to be listed individually in Question 3. (Aggregate Numbers Only)

Influenza like Illness (Respiratory Flu)
Definition: Any Child with pneumonia or fever and any of the following symptoms: sore throat, cough, generalized body aches. Vomiting and diarrhea alone is NOT respiratory flu.

Gastrointestinal Illness (Stomach Flu)
Definition: Any child with only vomiting and/or diarrhea.

Unknown "Flu"
Definition: Parent reports "my child has the flu" with no symptom information available.

COVID
Definition: Report COVID case numbers (staff and students), from all testing resources daily. Count a case only once, not each day of absence due to COVID. Exception: All positive results from tests conducted BY the school need to be reported on an individual basis to the Michigan Antigen Testing Results portal.

Non Flu Types

Strep Throat
Pink Eye (conjuctivitis)
Head Lice
Scarlet Fever
Fifth Disease
Impetigo
Mononucleosis
Encephalitis
Hepatitis
Tuberculosis

3. Specific Information- List all confirmed or suspected cases of communicable diseases including:

Select Add Another to add multiple students to the list.
Please report an unusual occurrence or outbreak of any disease or infection within 24 hours.

Student Name

Address

Phone

Date of Birth (MM/DD/YYYY)

Grade

Date 1st absent

Disease

Diagnosed By (Dr., parent, teacher, etc.)