Flu/H1N1 Reporting Form
Name of the individual with flu-like symptoms:
Student ID of the individual with flu-like symptoms:
Classification of Individual (select one):
Student Faculty Staff/Administration
If student, select one:
Campus Housing Commuter/Off Campus
Contact Information (please provide any available contact information such as email, cell phone, residence hall, friend, parent, ASU work location, etc.)This information will be used for follow-up and assistance:
If you are reporting for the individual who is ill, who notified you?
Student Friend Parent Administrator Other
If you are reporting for the individual who is ill, how were you notified?
Email Phone In Person
Your position:
Please provide your email address and phone number below if we may contact you about this individual:
Additional Comments: