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Reporting Influenza Type Virus in Residential Care

If you have a resident in your Residential Care center who has been experiencing flu-like symptoms, please fill out and submit the form below. Thank you.

Bold indicates required fields

E-Mail Address
Residential License #
Facilty Name
Director's Name
Physical Street Address
Zip Code
Center Phone Number
Emergency Afterhours Contact Phone Number

Please provide number not located at the center.
Why are you reporting?

Give brief description of the situation at your center
Current Census
How many residents appear to have flu-like symptoms?
Do you plan to close?
Type of Residential Center