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Hospital Influenza Surveillance Form

  1. Please complete items 1-8 on this form each Wednesday using the previous days (Tuesday) patient encounters for that 24-hour period. Then submit this form, by clicking on the submit form button below, to The Passaic County Department of Health by Wednesday at noon.

  2. mm/dd/yy

  3. (please elaborate, if necessary, in comments below)

  4. Enter Your email address here for follow-up if necessary

  5. Leave This Blank:

  6. This field is not part of the form submission.