Form No. 57.75FF Form No. 57.75FF Healthcare Worker Influenza Vaccination

OMB No. 0920-0666

Exp. Date: 02-29-2008

Healthcare Worker Influenza Vaccination

* Facility ID #: _____________ * Vaccination ID #: __________

Healthcare Worker Demographics:

* HCW ID #: _______________

HCW Name, Last: _________________ First: _____________ Middle: __________

* Gender: ___________ * Date of Birth: _____ / _____ / __________

* Performs direct patient care: _____ Y _____ N

Event Details:

* Type of vaccination: Influenza For season: _____________________

(specify years)

* Vaccine administered: ___Onsite at this facility

___Offsite at a location other than this facility

___ Declined vaccination

Reasons for declining: (select all that apply)

___ Fear of needles/injections

___ Fear of side effects

___ Perceived ineffectiveness of vaccine

___ Religious objections

___ Medical contraindications (e.g., allergy to vaccine components)

___ Current respiratory infection

___ Concern for transmitting vaccine virus to

contacts

___ Other (specify): ______________________________________

* Date of vaccination: ____ /____ /_______

mm dd yyyy

* Product: (check one) ___ Flumist® Manufacturer: ________________________________

___ Fluvirin®

___ Fluzone®

___ Fluarix®

* Type of influenza vaccine: ___ Live attenuated influenza vaccine (LAIV) e.g., nasal (Flumist®)

___ Inactivated vaccine (TIV) e.g., injectable (Fluvirin®, Fluzone®,

Fluarix®)

* Route of administration: ___ Intramuscular ___ Subcutaneous ___ Intranasal

* Lot number: _________________

*

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 57.75FF (Front) Ver. 1.1, Effective date XX/XX/200X

= Required for vaccines that are administered ONSITE.

* Adverse reaction to vaccine: ___ Y ___ N ___ Don’t know

If YES, select all that apply.

___ Arthralgia	___ Pain/soreness at injection site
___ Chills	___ Rash, generalized
___ Cough ___ Dypsnea	___ Rash, localized ___ Rhinorrhea
___ Fever	___ Sore throat
___ Headache	___ Swelling
___ Hives ___ Malaise/fatigue	___ Others (specify): __________________
___ Myalgia
___ Nasal congestion

* Which vaccine information statement, including edition date, was provided to the vaccinee?

____ Live, Attenuated Influenza Vaccine Information Statement

____ Inactivated Influenza Vaccine Information Statement

* Edition Date: ____ / ____ / ________

mm dd yyyy

Person Administering Vaccine:

* Vaccinator ID :__________________ (This is the HCW ID # for the vaccinator)

* Name, Last: _____________________ First: _____________ Middle: __________

* Work address: ________________________________________________________

* City: __________________ * State: _______ * Zip code: _______________

* Title: _____________________________________________

Custom

Label Label

_______________________ ____/____/____ _______________________ ____/____/____

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

Comments

CDC 57.75FF (Back) Ver. 1.1, Rev. 10/01/2005