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Get F M Cough 2012-2013 Influenza Report Form

L CASES Telephone (215) 685-6740 Fax (215) 238-6947 Form Available at hip.phila.gov Use this form to report suspected and confirmed cases of influenza who are either hospitalized (24 hours or more) or fatal. All other cases do not need to be reported by name, unless indicative of a new outbreak in a facility or institution requiring special containment measures. PATIENT DEMOGRAPHIC INFORMATION REPORT DATE LAST NAME FIRST NAME D.O.B STREET ADDRESS CITY TELEPHONE # Home Work.

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