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Influenza-Like Illness Notification Form

This form is designed for students who have flu-like symptoms. If you do have flu-like symptoms, please complete this form and submit it electronically by selecting “submit.” The form will be sent to the Student Health Center, Athletic Training, Dean of Students Office, and the Residence Life Office.

Name: *
Residence Hall & Room Number: *
E-mail Address: *
Cell Phone Number: *
Room Phone Number: *
Date on which you developed flu-like symptoms (mm/dd): *
Please provide any relevant details concerning your absence and your symptoms: *
Are you going home for the recovery process or will you self-isolate?: *		Go home (recommended by Cornell College and the Centers for Disease Control) Self-isolate

* Required Field

Influenza-Like Illness Notification Form

Self-Reporting Information