Form 57.211 Pre-season Survey on Influenza Vaccination Programs for

1. Facility ID #:______________________

   *Date Entered:_____________________                *For Season:________-_________

                 (Month/Year)                        (Specify years)

   *Vaccination campaign for: (check one)

1.  Seasonal influenza subtype    Non-seasonal influenza subtype   Both (campaign and target populations are the same for both subtypes)

1. *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:_______________________

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 57.211 (Front), Rev 1, v6.4

 

1. *6. Which of the following strategies do you plan to use to promote/enhance healthcare worker influenza vaccination at your facility?  (check all that apply)

            No formal promotional activities are planned

            Incentives

            Reminders by mail, email or pager

            Coordination of vaccination with other annual programs (e.g., tuberculin skin testing)

            Require receipt of vaccination for credentialing (if no contraindications)

            Campaign including posters, flyers, buttons, fact sheets

            Other, specify:

   *7. Do you plan to conduct any formal educational programs on influenza and influenza vaccination for your healthcare workers?

            Yes

            No

    8. If you plan to conduct formal educational programs on influenza and influenza vaccination, will your healthcare workers be required to attend?

            Yes

            No

   *9. Will you require healthcare workers who receive off-site influenza vaccination to provide documentation of their vaccination status?

            Yes

            No

   *10. Will you require signed declination statements from healthcare workers who refuse influenza vaccination?

            Yes

            No

   *11. Vaccine information statement edition date:  

           Seasonal:  _____/_____/_________       Non-seasonal: ____/____/________

                              mm     dd        yyyy                                   mm     dd        yyyy

1. CDC 57.211 (Back), Rev 1, v6.4

 

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Author	CDC
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File Created	2004-07-27