Contact Information School/Childcare Centre Name * Your Full Name * Your Email Address * Your Title/Position * Phone Number * Extension Absenteeism Information Is absenteeism ≥ 20% or is there an illness concern within a cluster? * Yes No Date of Absenteeism * Year202220232024 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Student Information Number of Ill Students * Total Students in School/Centre * Grades/Rooms of Ill Students Please select all applicable grades of ill students. Infant Toddler Preschool Before/After School JK SK 1 2 3 4 5 6 7 8 9 10 11 12 Entire School/Childcare Centre Other Other (please specify) Staff Information Number of Ill Staff * Total Staff in School/Centre * Symptoms Presenting Symptoms * Please select all applicable symptoms. If 'other' is selected, please specify in the field below. Nausea Vomiting Diarrhea Fever Cough Runny Nose Sore Throat Other Other Details Additional Details Recent school/centre activities or events Is food service offered on-site? * Yes No Please Submit this form to let us know absenteeism is now below 10%. Leave this field blank Submit