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Influenza Surveillance Forms

All ILI Surveillance Data must be submitted to the PCHD each week no later than Wednesday at 12 p.m. Please be sure to fill out the proper form for your organization.

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.

1. Surveillance Date:

2. Name of Hospital:

    Name of School:

3. City or Town:

4. County:
 Passaic      Morris

5. Total number of patient encounters on surveillance date?

6.  Number of patients ill with a diagnosis of influenza, viral syndrome or upper respiratory infection on surveillance date?


8. Reply Email Address:

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