P
OMB No. xxxx-xxxx Exp.
Date: xx-xx-20xx
* Required for saving **
Required for completion
Healthcare Personnel
*Facility ID #: ____________
*Date Entered: ___________________ *For Season: ____________________________
Month/Year (Specify years)
*Which personnel groups did you include in your annual influenza vaccination program this past season?
___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 did you include in your influenza vaccination program this season? (check all that apply)
___Full-time personnel
___Part-time personnel
___Contract personnel
___Volunteers
___Others, specify:_______________________
*At what cost did you provide influenza vaccine to your healthcare workers?
___No cost
___Reduced cost
___Full cost
*Did you provide influenza vaccination during all work shifts (including nights and weekends)?
___Yes
___No
*Which of the following methods did you use during influenza season to deliver vaccine to your healthcare workers? (check all that apply)
___Mobile carts
___Centralized mass vaccination fairs
___Peer-vaccinators
___Provided vaccination in congregate areas (e.g, conferences/meetings or cafeteria)
___Provided vaccination at occupational health clinic
___Other, specify_______________________________
*Which of the following strategies did you use to promote/enhance healthcare worker influenza vaccination at your facility? (check all that apply)
___No formal promotional activities were conducted
___Incentives
___Reminders by mail, email or pager
___Coordinated vaccination with other annual programs (e.g., tuberculin skin testing)
___Required receipt of vaccination for credentialing (if no contraindications)
___Campaign including posters, flyers, buttons, fact sheets
_
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-79, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC
57.75II (Front) Effective date : xx/xx/20xx
*Did you conduct any formal educational programs on influenza and influenza vaccination for your healthcare workers?
___Yes
___No
**If you conducted formal educational programs on influenza and influenza vaccination, did you require your healthcare workers to attend?
___Yes
___No
*Did you require healthcare workers who received off-site influenza vaccination to provide documentation of their vaccination status?
___Yes
___No
*Did you require signed declination statements from healthcare workers who refused influenza vaccination?
___Yes
___No
CDC
57.75II (Back) Effective date: xx/xx/20xx
File Type | application/msword |
File Title | Facility Level Variables on Influenza Vaccination Programs for Healthcare Workers |
Author | CDC |
Last Modified By | rfp9 |
File Modified | 2007-07-25 |
File Created | 2007-04-19 |