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Flu Self-Report Form Flu.gov Self-Evaluation

This form is for students to self-report any illness that appears to be flu-like. By completing this form, you give authorization to submit your information to the offices checked. Completing this form does not excuse a student from class.  The form will be used to increase communication between offices and assist the University in responding to your situation. 

You may wish to complete the H1N1 Flu Self-Evaluation before using this form.

Please see the Influenza-Like Illness Case Definition or the Pandemic Flu page for more information on flu-like illnesses.

Flu Self-Report Form

Leave this field empty
Name*
Student ID*
E-mail Address*
Cell Phone*
Residence*
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In Dorm/Room:*
Address:*
Symptoms*
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  •  
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Fever Onset Date*
Sore Throat Onset Date*
Cough Onset Date*
Offices to be notified
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(Brady Health and Student and Educational Services notified in all cases)
By completing and submitting this form, I verify that the information I have provided is true.