Record the number of patients for each category below for the month being reviewed.
|
*Facility ID# :
|
*Vaccination type: Influenza
| *Influenza subtype:
| *Month
| *Year:
|
Patient categories
| Number of patients in each category
|
*1. Total # of patient admissions
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*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
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*4. Total patients not previously vaccinated during current influenza season (Box 2 – Box 3)
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*5. Patients meeting criteria offered vaccination but declining for reasons other than medical contraindication.
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*6. Patients meeting criteria offered vaccination but having medical contraindication
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*7. Patients meeting criteria receiving vaccination during admission
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*8. Total patients offered vaccination (Box 5 + Box 6 + Box 7)
| |