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ICR 200908-0920-002 · OMB 0920-0666 · Object 13199801.
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| File Type | application/vnd.ms-powerpoint |
|---|---|
| File Title | Slide 1 |
| Author | CDC |
| Last Modified By | Impress |
| File Modified | 2007-07-26 |
| File Created | 2026-09-20 |
| Conversion State | complete |
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High Risk Inpatient Influenza Vaccination Monthly Monitoring Form – Method B OMB No. xxxx-xxxx Exp. Date: xx-xx-20xx * required for saving Record the number of patients for each category below for the month being reviewed. *Facility ID# : *Vaccination type: Influenza *Month: Patient categories *Year: Number of patients in each category *1. Total # of patient admissions 2. Total # of patients previously vaccinated during current influenza season *3. Total # of patients meeting high risk criteria previously vaccinated during current influenza season Optional fields: Label __________ __________ __________ __________ __________ Data __________ __________ __________ __________ __________ 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 4 hours 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 57.75RR Effective date xx/xx/20xx