*1. Which personnel groups do you plan to include in your annual influenza vaccination program?
All personnel who work in the facility
All personnel who work in clinical areas, including those without direct patient care duties (e.g., clerks, housekeepers)
Only personnel with direct patient-care duties (e.g, physicians, nurses, respiratory therapists)
*2. Which of the following types of employees do you plan to include in your annual influenza vaccination program? (check all that apply)
Full-time employees Number ________
Part-time employees Number ________
Contract employees Number ________
Volunteers Number ________
Others, specify:_______________________ Number ________
*3. At what cost will you provide influenza vaccine to your healthcare workers?
No cost
Reduced cost
Full cost
*4. Will influenza vaccination be available during all work shifts (including nights and weekends)?
Yes
No
*5. Which of the following methods do you plan to use this influenza season to deliver vaccine to your healthcare workers? (check all that apply)
Mobile carts
Centralized mass vaccination fairs
Peer-vaccinators
Provide vaccination in congregate areas (e.g, conferences/meetings or cafeteria)
Provide vaccination at occupational health clinic
Other, specify:_______________________