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• Text - Notification Form

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→ Suspected Influenza Case at Work Notification Form

Suspected Influenza Case at Work Notification Form

Details of Affected Staff

Name:
Job Title:
Worksite:
Location of Isolation:
Nationality if Visitor to Site:
Date of Birth:
Address:
Telephone Number
(W):
(H):
(M):

Symptoms noticed

• Fever
• Headache
• Dry cough
• Cold
• Body ache
• Fatigue
• Others - Details:

Travel history over the past 8 days

• Countries visited:
• Flights taken:

Where referred:

Contact List: (see separate page)

Details of Reporter

Name:
Job title:
Telephone number
(W):
(H):
(M):