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Influenza Type Virus in Child Care Centers

If you are experiencing a high number of children in your child care center experiencing flu-like symptoms, please fill out and submit the form below. Thank you.

E-Mail Address

Child Care License #

Facilty Name

Contact Name

Physical Street Address

City

Zip Code

Center Phone Number

Emergency Afterhours Contact Phone Number

Please provide number not located at the center.

Do you receive CCAP?

Yes No

Are you a licensed facility?

Yes No, I provide home care.

Why are you reporting?

Give brief description of the situation at your center

Typical Number of Children Attending on Normal Day

How many children appear to have flu-like symptoms?

Do you plan to close?

Yes No Unsure

Ages Served at the Child Care

Infants under 12 months One Year Old Two Year Old Three Year Old Four Year Old Five Year Old Six Year Old and up Please check all that aply