Mock CDC Influenza Reporting Form
Patient Information:
First Name:
Last Name:
Date of Birth: (mm/dd/yy)
Disease/Condition Information:
Type:
A
B
Sub-type:
H1N1
H1N2
H3N2
Event and Date
Event:
Onset
Diagnosed
Event Date (mm/dd/yy):
Person Making Report:
First Name:
Last Name:
e-mail:
Comments: