Record the number of patients for each category below for the month being reviewed.
|
*Facility ID# :
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*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
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3. Total # of patients previously vaccinated during current influenza season
| |
*4. Total patients not previously vaccinated during current influenza season (Box 2 – Box 3)
| |