Form CDC 57.133 CDC 57.133 Patient Vaccination

The National Healthcare Safety Network (NHSN)

57.133_PtVacc_BLANK.ppt

57.133_Patient Vaccination

OMB: 0920-0666

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  1.  *Facility ID:

  1. *Event #:

  1. *Patient ID:

  1. Social Security #:

  1. Secondary ID:

 
  1. Patient Name, Last:                                      First:                                           Middle:

  1. *Gender:    F      M      Other

  1. *Date of Birth:

  1. Ethnicity (specify):

  1. Race (specify):

  1. *Event Type: FLUVAX

  1. *Influenza subtype: Seasonal   Non-Seasonal

  1. *Date Admitted to Facility:

  1. *Vaccine offered: Yes No

  1. *Vaccine declined: Yes No

  1. Reason(s) vaccine declined (Check either section A or B but not both)

  1. A.  Medical contraindication(s) (check all that apply):

  1. B. Personal reason(s) for declining (check all that apply):

  1. Allergy to vaccine components                

    History of Guillian-Barre syndrome within 6 weeks of previous influenza vaccination

    Current febrile illness (Temp > 101.5°F)

    Other (specify): ____________________________

  1. Fear of needles/injections                        

    Fear of side effects

    Perceived ineffectiveness of vaccine        

    Religious or philosophical objections

    Concern for transmitting vaccine virus to contacts

    Other (specify): _________________________

  1. *Vaccine administered: Yes     No

  1. ^Date Vaccine Administered:

  1. ^Type of influenza vaccine administered:

  1. Seasonal:          Afluria®             Agriflu        ®                 Fluarix®    FluLaval®          Flumist®

                            Fluvirin®       Fluzone®            Fluzone High-Dose®                 Other (specify) ____________________

    Non-seasonal: Other (specify) _____________________________

     Live attenuated influenza vaccine (LAIV) e.g., nasal     Inactivated vaccine (TIV)

    ^Manufacturer: _____________________________          ^Lot number: _______________________

  1. ^Route of administration:     Intramuscular           Intranasal             Subcutaneous

  1. Vaccine Information Statement (VIS) Provided to Patient:

  1. Live Attenuated Influenza VIS               Inactivated Influenza VIS         None or unknown

  1. Edition Date: ________/_________/________

  1. Person Administering Vaccine:

  1. Vaccinator ID:

  1. Title:

  1. Name: Last:                                         First:                                          Middle:

  1. Work Address:  _________________________________________________________________________

    City:_____________________________  State: _________________________  Zip code: _____________

  1. Assurance of Confidentiality:  The voluntarily provided 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-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

    CDC 57.133 rev 3, v 6.4

 
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  1. Comments

 

 
File Typeapplication/vnd.ms-powerpoint
File TitleSlide 1
AuthorCDC
Last Modified Byano3
File Modified2010-12-12
File Created2004-07-27

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