*Facility ID:
| *Event #:
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*Patient ID:
| Social Security #:
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Secondary ID:
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Patient Name, Last: First: Middle:
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*Gender: F M
| *Date of Birth:
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Ethnicity (specify):
| Race (specify):
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*Event Type: FLUVX
| Vaccination type: Influenza
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*Date of Admission:
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*High Risk Criteria (For patients not previously vaccinated only, check all that apply)
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Adult aged > 49 years Child aged 6 – 59 months Residents of nursing homes or other chronic-care facilities Pregnancy during the influenza season Child/adolescent (aged 6 months–18 years) receiving long-term aspirin therapy Adult or child over 6 months of age who has**:
•chronic disorders of the pulmonary or cardiovascular systems, including asthma (hypertension is not considered a high-risk condition) •required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunodeficiency (including immunodeficiency caused by medications or by human immunodeficiency virus [HIV]) •any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration
(**See Table 1 for further information on high risk disease conditions)
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*Vaccine Offered: Yes No (If Yes complete HRIIV Numerator Data Form – Method B, CDC 57.75QQ)
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Table 1 - ICD9 codes associated with high risk disease conditions that may make patients candidates for influenza vaccination (may not be all inclusive). CHECK ALL THAT APPLY.
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HIGH-risk category
| HIGH-risk sub-category
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Chronic pulmonary
| Acute rheumatic fever Chronic rheumatic heart disease Hypertensive heart disease Ischemic heart disease Diseases of pulmonary circulation Other forms of heart disease* Atherosclerosis, polyarteritis nodosa Congenital anomalies Surgical/device conditions (heart transplant, cardiac device in situ, aortocoronary bypass, angioplasty) Cardiovascular syphilis Candidal endocarditis Myocarditis due to toxoplasmosis
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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 5 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 57.75SS (Front) Effective date xx/xx/20xx
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