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Among the entities that track attendance most closely in American society are primary and secondary schools. School districts track attendance because of statutory responsibility. Virtually all states mandate school attendance. In California, the attendance tracking must be supplemented by some effort to ascertain if an illness caused the absence or it is unexcused. State Education Code 46011 reads, "Absences due to illness or quarantine shall be verified by the district or the county superintendent of schools in such manner as the Superintendent of Public Instruction may provide." As a result, in California and most other states, schools make routine queries of parents into the causes of absensteeism.

Schools also track absenteeism because of both fiduciary and financial responsibilities. Absenteeism is correlated with poor academic performance, social difficulties in school, and dropping out from high school prior to graduation (Weitzman et al., 1986).

A percentage of absenteeism is known to be due to either chronic illness or severe personal or family life problems confronting students. At a certain point, students who miss an excessive amount of school become difficult to educate (six to 10 days per quarter), and those missing more require extraordinary efforts (Weitzman et al., 1986). Therefore, concern for students' welfare is also an important factor. From a financial perspective, states compensate many districts on the basis of average daily attendance; as a result, school districts have direct financial incentive to ensure students attend classes. As a result, most school districts place a high priority on detection of high rates of absenteeism and expend considerable effort determining if a child's absence is illness related or unexcused.

Attendance management in schools is a complex process that depends on the organizational preferences of districts and even of schools. Every school and district with will vary to some extent. In the Chula Vista Elementary School District (a school district in southern California that is typical of size and funding levels of districts in the state), the processes for management of attendance are focused around the attendance clerk. This individual, who probably has a high school education and earns near minimum wage, is responsible for producing, at the end of the day, and updating, as the week unfolds, a report on the number of absences, including whether a particular student's absence is due to illness or medical necessity.

Figure 24.1 illustrates the process. Absence data initially comes to the attendance clerk from parents by telephone, by personal communications from parents dropping off other children at school, and by notes sent to school with siblings. The percentage of children absent without any parent contact varies from 20% to 60% of absences depending on the school.

figure 24.1 Current work flow for attendance reporting in the Chula Vista schools.

School clerks merge these data with attendance records from teachers of the first period class.The clerks attempt to determine which students have excused absences. As children who are late for legitimate and other reasons arrive, clerks then edit the absentee list. Attendance clerks also may attempt to determine the causes for unexplained absences by calling parents at home. Some districts use automated calling systems to inform parents of unexcused absences during evening hours. The final rate of unexplained absences varies among schools in the district depending on the motivation of the clerk and the time he or she has available for following up on the unexplained absences. At the end of each business day, clerks manually enter the absence data they have collected into the district's computer database. Clerks update the absence records for each day throughout the school week, as they collect data or receive information from parents documenting that absences are due to illnesses or medical appointments or other excusable causes.

A parent or guardian typically supplies the reason for an absence. There are no standards for documentation of illnesses and most systems assume parents are cooperative participants who are working with the district to insure appropriate attendance. Of course, in some circumstances, absenteeism may be due to the personal problems or preferences of a parent for holiday or leave time.As argued by Weitzman et al. (1986) and later by Alberg et al. (2003), school absenteeism patterns result from complex interactions between multiple factors. While child health is a major contributor, parent or sibling health or parent preferences for vacation time may be the cause.

Many school districts use computer technology to track student attendance. There are no published data on the rates of use of software systems. Attendance software may be a stand alone product focused just on this activity or may be embedded in a district wide student management system that manages grading, health records, and other information. The technology for attendance management is rapidly advancing. Recent developments include the use of personal digital assistants and either wireless or wired synchronization technologies that allow teachers to report attendance and automatically integrate reports. However, as with any information technology, the range of technologies used within a region may vary greatly. Furthermore, technicians have not designed these systems for interoperability.

Software for tracking attendance in many districts is supplemented by digital telephony communication systems. These systems can be programmed to call the homes of students with a recorded message, and it is not an uncommon practice to call the home of absent students who were not excused for illness to inform parents or guardians. The current objective of such systems is to inform parents of absenteeism, but it might be possible to expand the role to collect better data on the cause of absenteeism by using these same systems to collect data through interactive questionnaires.

Absenteeism offers only a partial picture of the effects of outbreaks on student health. Other data sources, such as information about students sent home with illness and the symptoms they are experiencing, can help complete the picture. If the primary objective is subpopulation health monitoring, these other sources of data may be invaluable in understanding events.

Public health officials attempting to integrate attendance results from the schools and school districts in a region face problems akin to those encountered with the use of medical data from hospitals for outbreak detection. There are numerous disparate and incompatible data sources and few financial incentives for districts to collaborate with public health officials. While there are significant technical issues for integration of data, probably the greatest issues are legal and political. Technical issues include connectivity and strategies for merging data and forwarding reports to public health officials in a timely way. Legal and political issues focus upon privacy considerations similar to those raised by compliance with the Health Insurance Portability and Accountability Act (HIPAA). In personal interviews conducted by one of the authors, one large school district's CIO indicated that the preference would be for "off-line" access. Similar to the approach used for hospital data in ESSENCE (Lombardo et al., 2004), school districts would need to configure attendance systems to report anonymous attendance data to public health authorities at regular intervals. Schools without computing infrastructure for attendance reporting might need to use a "drop-in" style system where clerks used a website or a telephone computer system to report overall absenteeism figures.

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