MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20

Resident _______________________________________________________

Numeric Identifier______________________________________

MINIMUM DATA SET (MDS) - VERSION 2.0
FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
SECTION W. SUPPLEMENTAL MDS ITEMS
1.

National Enter for all assessments and tracking forms, if available.
Provider
ID

If the ARD of this assessment or the discharge date of this discharge
tracking form is between July 1 and September 30, skip to W3.

2.

Influenza
Vaccine

a . Did the resident receive the Influenza vaccine in
this facility for this year’s Influenza season
(October 1 through March 31)?
0. No (If No, go to item W2b)
1. Yes (If Yes, go to item W3)
b.

3. Pneumococcal
Vaccine

If Influenza vaccine not received, state reason:
1. Not in facility during this year’s flu season
2. Received outside of this facility
3. Not eligible
4. Offered and declined
5. Not offered
6. Inability to obtain vaccine

a. Is the resident’s PPV status up to date?
0. No (If No, go to item W3b)
1. Yes (If Yes, skip item W3b)
b.

If PPV not received, state reason:
1. Not eligible
2. Offered and declined
3. Not offered

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0739. The time required to complete this information
collection is estimated to average .7053 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

MDS 2.0 October 2006