School Dismissal Monitoring System (Reporting Form)

OMB Control No. 0920-xxxx

Exp. Date xx/xx/xxxx

Novel Influenza A (H1N1)-Related School Dismissal Reporting Form

The Centers for Disease Control and Prevention and the U. S. Department of Education have established a School Dismissal Monitoring System to report on novel influenza A (H1N1)-related school or school district dismissals in the United States. Your assistance in reporting known school dismissals is very important.

Note:

• For district-wide dismissals, only provide the name of the school district. It is not necessary to list all the individual schools in the school district.

• For single school dismissals, provide the name of only the individual school.

• For multiple school dismissals (but not district-wide), complete a separate form for each school.

Top of Form

Required *

Name of school or school district:*
Zip code of school or school district:*	(5 Digit Format)
Date school or school district dismissed:*	(yyyy-mm-dd)
Date school or school district is projected to re-open: (if known)	(yyyy-mm-dd)

 

Optional

Name of person submitting this form:
Organization/Agency:
Phone:
Email:

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-xxxx.