Weekly Physician Report of Influenza-Like Illness (ILI)
The information submitted to the local health department is essential to the ongoing surveillance and assessment of ILI activity within our communities in Clinton, Gratiot and Montcalm Counties.
Week Beginning Sunday
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practice Name
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
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Influenza-Like Illness (Respiratory Flu)
Any individual presenting with a fever of 100°F or higher, accompanied by a cough and/or sore throat meets the criteria for ILI. Additional possible symptoms include malaise, muscle aches, vomiting, or diarrhea. However, vomiting/diarrhea alone does NOT constitute respiratory flu.
Number of cases tested for Flu
Number of Influenza A positive
Number of Influenza B positive
Number of cases Not Tested
Number of cases tested with no subtype/classification
No Disease to Report
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Submitter Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email address (copy of this form will be emailed to you after submission)
example@example.com
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