Form 57.209 Healthcare Worker Influenza Vaccinatuion

Facility ID:		Vaccination #:
Healthcare Worker Demographics
*HCW ID#:
HCW Name, Last:                First:                Middle:
*Gender:      F      M      Other        *Date of Birth:
*Work Location:                 *Occupation:                              Clinical Specialty:
*Performs direct patient care:          Yes         No
Vaccination Details
*Type of vaccination: Influenza     *Influenza subtype:      Seasonal (years) _____________  Non-seasonal  (years) ____________  *Do you plan to use this information to satisfy federal record-keeping requirements for the administration of vaccine covered by the Vaccine Injury Compensation Program?  Yes    No *Vaccine administered:         Onsite at this facility                  Offsite at a location other than this facility                  Declined due to medical contraindications                                              (e.g.,allergy to vaccine components)                  Declined due to personal reasons                     If declined for personal reasons: (check all that apply)                                  Fear of needles/injections                                  Fear of side effects                                  Perceived ineffectiveness of vaccine                                  Religious or philosophical objections                                  Concern for transmitting vaccine virus to contacts                                  Other (specify):                                                *Date of vaccination:_____ / _____ / _____                            mm           dd         yyyy *Product: (check one)         Seasonal:               Non-seasonal:                                      Afluria®             2009 H1N1:  CSL Limited                                      Agriflu®                  Fluarix®                                              Novartis and Diagnostics, Ltd.                  Flulaval®                                            Sanofi Pasteur, Inc.                  Flumist®                                             MedImmune LLC                  Fluvirin®                 Other (please specify)_________________                              Fluzone® *Lot number:                                                   Manufacturer:        ______________ *Type of influenza vaccine:         Live attenuated (LAIV) [e.g., nasal (Flumist®)]                  Inactivated vaccine(TIV)[e.g., injectable(Fluvirin®,Fluzone®,Fluarix®,                                               FluLaval®, Afluria®)] *Route of administration:         Intramuscular                  Intranasal                  Subcutaneous
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 57.209 (Front) rev.3, v6.4

 

Event Details (cont.)
*Adverse reaction to vaccine:  Yes      No      Don’t know If Yes, check all that apply:  Arthralgia                 Pain/soreness at injection site         Chills                 Rash, generalized  Cough                 Rash, localized  Fever                 Rhinorrhea  Headache                 Shortness of breath/difficulty breathing  Hives                 Sore throat  Malaise/fatigue         Swelling  Myalgia                 Other (specify):__________________________  Nasal congestion Which vaccine information statement, including edition date, was provided to the vaccinee?  Live Attenuated Influenza Vaccine Information Statement  Inactivated Influenza Vaccine Information Statement Edition date:_____ / _____ / _____                  mm           dd          yyyy
Person Administering Vaccine
Vaccinator ID :_____________________ (This is the HCW ID# for the vaccinator) Name, Last:__________________  First:_____________________ Middle: __________________ Title: ___________________________________________________________ Work address: ___________________________________________________________________ City: _________________________  State: ________________ Zip code: ______________
Custom Fields
Label ________________________   ___/___/___ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________	Label   ________________________   ___/___/___   ________________________   ___________   ________________________   ___________   ________________________   ___________   ________________________   ___________   ________________________   ___________   ________________________   ___________
Comments
CDC 57.209 (Back) Rev. 3, v6.4

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-08-11
File Created	2004-07-27

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