Illness Surveillance Form

Illness Surveillance Form

Wildflower Nature School (970) 760-6950
Full Name of individual who is sick*

First NameLast Name
Description of individual:*

A child enrolled in schoolA staff member at work
Child's Date of Birth

MonthDayYear
Date
Age in Months
Where did the illness begin?*

Stayed home from school/workSent home from school/ left workRemained at school/work
Does this child have a sibling?

Yes- sibling enrolled at WNSYes- sibling NOT enrolled at WNSNo siblingUnsure
Symptoms*

VomitingDiarrheaFeverAbdominal CrampsHeadacheChillsMuscle AchesRashCoughEyes (red or discharge)LethargicRespiratoryLack of AppetiteUnknownOther
Description if applicable (intensity/ frequency/ duration)
V=Vomiting, D=Diarrhea, F=Fever, A=Abdominal Cramps, H=Headache, C=Chills, M=Muscle Aches R=Rash
Onset of Symptoms (or your best estimate)*

MonthDayYear
Date
Hour MinutesAM/PM Option
Symptom Duration (hours)
Treatment of Symptoms if applicable (Actions Taken by Parent, Teacher, Admin)
Specific treatment provided (first aide, administered medication, etc.), sent home, sent back to group care, excluded for 48 hours, isolated, hospitalized, etc.
Today's Date

MonthDayYear
Date
Next Date Scheduled to come back to school/work

MonthDayYear
Must be 24 hours after last known symptom.
Your Name (adult filling out this form)*

First NameLast Name
Date and time returned to care (if not returned yet, admin will update in future).

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: