Record the number of healthcare personnel (HCP) for each category below for the month being reviewed.
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*Facility ID# :
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*Vaccination type: Influenza
| *Influenza subtype:
| *Month
| *Year:
| |
HCP categories
| Employees
| Non-Employees, Credentialed
| Non-employees, Other
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*1. Have worked at this healthcare institution between October 1 and March 31
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*2. Received an influenza vaccine at this healthcare institution
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*3. Received an influenza vaccine elsewhere
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*4. Have a medical contraindication to the influenza vaccine
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*5. Declined to receive the influenza vaccine for non-medical reasons
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The number of occupational groups receiving vaccination:
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| | 6. Nursing professionals
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| | 7. Physicians
| |
| | 8. Credentialed allied health professionals and technicians
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| | 9. Students/clinical trainees
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| | 10. Support services personnel and volunteers
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| | 11. Administrative personnel
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Comments
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