H1N1 Tracking Form

H1N1 Influenza

If you have contracted the H1N1 flu, please let us know by completing the form below.

  • This is for tracking purposes only. No information will be collected that can identify you.

Thank you for your assistance.

Gender:
Gender:
Affiliation with LCCC:
Affiliation with LCCC:
 
Campus Location:
Campus Location:
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