Form 57.212 Post-season Survey on Influenza Vaccination Programs for

1. Facility ID #:______________________

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

                 (Month/Year)                        (Specify years)

1. *Vaccination campaign for:(check one)

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

1. *1. Which personnel groups did you include in your annual influenza vaccination program this past season?

            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 did you include in your annual influenza vaccination program this past season? (check all that apply)

            Full-time employees     Number _______

            Part-time employees     Number _______

            Contract employees      Number _______

            Volunteers                   Number _______

            Others, specify:_______________________  Number ________

   *3. At what cost did you provide influenza vaccine to your healthcare workers?

            No cost

            Reduced cost

            Full cost

   *4. Did you provide influenza vaccination during all work shifts (including nights and weekends)?

            Yes

            No

   *5. Which of the following methods did you use during influenza season to deliver vaccine to your healthcare workers? (check all that apply)

            Mobile carts

            Centralized mass vaccination fairs

            Peer-vaccinators

            Provided vaccination in congregate areas (e.g, conferences/meetings or cafeteria)

            Provided 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 57.212 (Front), Rev 1, v6.4

 

1. *6. Which of the following strategies did you 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)

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

            Campaign including posters, flyers, buttons, fact sheets

            Other, specify:

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

            Yes

            No

    8. If you conducted formal educational programs on influenza and influenza vaccination, did you require your healthcare workers to attend?

            Yes

            No

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

            Yes

            No

   *10. Did you require signed declination statements from healthcare workers who refused influenza vaccination?

            Yes

            No

1. CDC 57.212 (Back), Rev 1, v6.4

 

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File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-08-12
File Created	2004-07-27