Form CDC 57.213 CDC 57.213 Healthcare Personnel Influenza Vaccination Monthly Summa

Record the number of healthcare personnel (HCP) for each category below for the month being reviewed.
*Facility ID# :
*Vaccination type: Influenza		*Influenza subtype: Seasonal    Non-seasonal	*Month	*Year:
HCP categories			Employees	Non-Employees, Credentialed	Non-employees, Other
*1. Have worked at this healthcare institution between October 1 and March 31
*2. Received an influenza vaccine at this healthcare institution
*3. Received an influenza vaccine elsewhere
*4. Have a medical contraindication to the influenza vaccine
*5. Declined to receive the influenza vaccine for non-medical reasons
The number of occupational groups receiving vaccination:
	6. Nursing professionals
	7. Physicians
	8. Credentialed allied health professionals and   technicians
	9. Students/clinical trainees
	10. Support services personnel and volunteers
	11. Administrative personnel
Comments

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	fom7
File Modified	2010-09-21
File Created	2010-06-04