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OMB No. 0920-0666
Exp. Date: xx-xx-xxxx

Vaccination Monthly Monitoring Form–
Patient-Level Method

* required for saving

Page 1 of 1

Record the number of patients for each category below for the month being reviewed.
*Facility ID# :
*Vaccination type: Influenza

*Influenza subtype:

 Seasonal

 Non-seasonal

Patient categories

*Month:

*Year:

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
3. Total # of patients previously vaccinated during current influenza
season
*4. Total patients not previously vaccinated during current influenza
season (Box 2 – Box 3)

Optional fields:
Label

__________ __________ __________ __________ __________

Data

__________ __________ __________ __________ __________

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 2 hours 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 57.131 rev 1, v6.4