Form No. 57.75HH Form No. 57.75HH Pre-Season Survey on Influenza Vaccination Programs

Form Approved

OMB No. 0920-0666

Exp. Date 2/29/2008

F

OMB No. 0920-0666

Exp. Date: 02-29-2008

XX-XX-XXXX

acility ID #: ____________ Pre-season Survey on Influenza Vaccination Programs for

Healthcare Workers

Facility ID #: ____________

Date Entered: ___________________                For Season: ____________________________

Month/Year (Specify years)

Which personnel groups do you plan to include in your annual influenza vaccination program?

___All personnel who work in the facility

___All personnel who work in clinical areas, including those without direct patient care duties

(e.g., clerks, housekeepers)

___Only personnel with direct patient-care duties (e.g, physicians, nurses, respiratory therapists)

Which of the following types of personnel do you plan to include in your annual influenza vaccination program? (check all that apply)

___Full-time personnel

___Part-time personnel

___Contract personnel

___Volunteers

___Others, specify _______________________

At what cost will you provide influenza vaccine to your healthcare workers?

___No cost

___Reduced cost

___Full cost

Will influenza vaccination be available during all work shifts (including nights and weekends)?

___Yes

___No

Which of the following methods do you plan to use this influenza season to deliver vaccine to your healthcare workers? (check all that apply)

___Mobile carts

___Centralized mass vaccination fairs

___Peer-vaccinators

___Provide vaccination in congregate areas (e.g, conferences/meetings or cafeteria)

___Provide vaccination at occupational health clinic

___Other, specify_______________________________

Which of the following strategies do you plan to use to promote/enhance healthcare worker influenza vaccination at your facility? (check all that apply)

___No formal promotional activities are planned

___Incentives

___Reminders by mail, email or pager

___Coordination of vaccination with other annual programs (e.g., tuberculin skin testing)

___Require receipt of vaccination for credentialing (if no contraindications)

___Campaign including posters, flyers, buttons, fact sheets

___Other, specify

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

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 57.75HH (Front) Ver. 1.1, RevEffective date. 10XX/01XX/200X5

Do you plan to conduct any formal educational programs on influenza and influenza vaccination for your healthcare workers?

___Yes

___No

If you conduct formal educational programs on influenza and influenza vaccination, will your healthcare workers be required to attend?

___Yes

___No

Will you require healthcare workers who receive off-site influenza vaccination to provide documentation of their vaccination status?

___Yes

___No

Will you require signed declination statements from healthcare workers who refuse influenza vaccination?

___Yes

___No

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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0666).

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