Attention: School Principal Date:



Attention: School Principal Date:

Name of Parent/Guardian

Report of Communicable Diseases in the School

The diagnosis of communicable diseases is as follows:

|Student's Name |Grade: Class: |

|Medical Organization | |Date of consultation: |

|Name: | | |

| Name of Disease (please check the □) |

|Type 1 |□ Ebola Hemorrhagic Fever |

| |□ Crimean Congo Hemorrhagic Fever |

| |□ Smallpox |

| |□ South American Hemorrhagic Fever |

| |□ Pestilence |

| |□ Marburg Hemorrhagic Fever |

| |□ Lassa Fever |

| |□ Acute Poliomyelitis |

| |□ Diphtheria |

| |□ Severe Acute Respiratory Syndrome |

| |□ Avian Influenza |

|Type 2 |□ Influenza |

| |□ Pertussis |

| |□ Measles |

| |□ Epidemic Parotitis (Mumps) |

| |□ Rubella |

| |□ Chicken Pox |

| |□ Pharyngoconjunctival Fever (PCF) |

| |□ Tuberculosis |

|Type 3 |□ Cholera |

| |□ Bacillary Dysentery |

| |□ Enterohemorrhagic Escherichia Coli |

| |□ Abdominal Typhus (Typhoid) |

| |□ Paratyphoid Fever |

| |□ Epidemic Keratoconjunctivitis (EKC) |

| |□ Acute Hemorrhagic Conjunctivitis (AHC) |

| |□ Other Communicable Diseases |

| |□ Hemolytic Streptococcal Infection |

| |□ Hand, Foot and Mouth Disease |

| |□ Mycoplasma Pneumonia |

| |□ Others |

| |( ) |

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