Form CDC 57.130 CDC 57.130 Vaccination Monthly Monitoring Form-- Summary Method

Record the number of patients for each category below for the month being reviewed.
*Facility ID# :
*Vaccination type: Influenza	*Influenza subtype: Seasonal    Non-seasonal	*Month	*Year:
Patient categories			Number of patients in each category
*1. Total # of patient admissions
*2. Total # of patients aged 6 months and older meeting criteria for influenza vaccination
3. Total # of patients previously vaccinated during current influenza season
*4. Total patients not previously vaccinated during current influenza season (Box 2 – Box 3)
*5. Patients meeting criteria offered vaccination but declining for reasons other than medical contraindication.
*6. Patients meeting criteria offered vaccination but having medical contraindication
*7. Patients meeting criteria receiving vaccination during admission
*8. Total patients offered vaccination (Box 5 + Box 6 + Box 7)

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-12-10
File Created	2004-07-27