Student Influenza Like Illness (ILI)/H1N1 Reporting Form

Northwestern University Health Service

 

Please use this form after you have completed the "I Think I May Have H1N1 Influenza" Self-Reporting Form or you have spoken with a Health Service clinician.  Be sure to note which "Outcome" you have been assigned.

Last name:          First name/Middle initial:    

Student ID number (7 digits from NU WildCARD:              

Email address:    

Telephone:    

Select the appropriate H1N1 outcome below:

7.  On the basis of your answers, you likely DO NOT HAVE H1N1 INFLUENZA, although you may be suffering from another medical condition.

8.  On the basis of your answers, you DO QUALIFY AS A "SUSPECT CASE" OF H1N1 INFLUENZA, although only laboratory testing can  prove the diagnosis.

9.  On the basis of your answers, you DO QUALIFY AS A "SUSPECT CASE" OF H1N1 INFLUENZA,  AND YOU ARE EXPERIENCING SYMPTOMS THAT MAY INDICATE SEVERE DISEASE.

10.  On the basis of your answers, you DO QUALIFY AS A "SUSPECT CASE" OF H1N1 INFLUENZA, AND YOU HAVE ONE OR MORE CONDITIONS THAT MAY INCREASE YOUR RISK OF SERIOUS COMPLICATIONS FROM H1N1 INFECTION.

11.  On the basis of your answers, IT IS UNCLEAR WHETHER YOU HAVE H1N1 INFLUENZA, and you may be suffering from another medical condition such as strep throat or infectious mononucleosis ("mono").

Other Comments (300 characters maximum):

 

If you live on campus, please complete the following:

Do you live in a NU Residence Hall/Residential College?  yes        no              If "yes," please select:

Residence Hall/Residential College Room Number: 

If not, do you live in a Greek Life residence?  yes        no        If "yes,"  please select: 

If you live off-campus, please provide your address: 

  Street Address/Apartment#: 

City:       State:        Zipcode: 

Are you a member of any of the NCAA Division 1 Intercollegiate Sports (click all that apply)? 

Men Women
baseball basketball
basketball cross country
football fencing
golf field hockey
soccer golf
swimming and diving lacrosse
tennis soccer
wrestling softball
  swimming and diving
tennis
volleyball

Other Groups

Cheerleading

Ladycats

Club Sports     Specify: 

Music Groups    Specify: 

Theatre Groups    Specify: 

Other groups with which you have close contact.  Specify: 

 Do you want to request:

Please verify all of your responses before clicking on the "submit" button below.

Thank you for providing this information.  It will allow the University to monitor for significant cluster outbreaks of illness as well as to help protect those students who may be at high risk of severe complications.