Do You Have Flu or Flu-Like Symptoms?
Students, Staff, and Faculty are encouraged to self-identify if you have any flu-like symptoms by providing the following information. Individual information will be shared with the appropriate university personnel in order to address health needs. Otherwise, information will be shared in summary only, non-specific to individuals.
Residence Hall, Room # or Address
Date of Birth:
Date Symptoms Began:
I have the following symptoms. Flu symptoms generally occur suddenly and not gradually. (Please mark all that apply):
Fever greater than 100°F
Runny or Stuffy Nose
I have seen a doctor.
Dr. __________________ has diagnosed me with _____________
Instructions or Medications Given:
I am taking over-the-counter medications that include:
I have been vaccinated with
Seasonal Influenza Vaccine
Intranasal Influenza Vaccine
H1N1 Influenza Vaccine
Approximate date of vaccination:
People with serious illness and those at high risk for complications from influenza should contact their medical provider or seek medical care. I have the following serious medical conditions: