Form 57.130 Vaccination Monthly Monitoring - Summary Method

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Vaccination Monthly Monitoring Form-Summary Method

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Record the number of patients for each category below for the month being reviewed.
*Facility ID#:
*Vaccination type: Influenza	*Influenza subtype: □Seasonal □Non-Seasonal		*Month		*Year
Patient categories				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)
*5. Patients meeting criteria offered vaccination but declining for reasons other than medical contraindication
*6. Patients meeting criteria offered vaccination but having medical contraindication
*7. Patients meeting criteria receiving vaccination during admission
*8. Total patients offered vaccination (Box 5 + Box 6 + Box 7)

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 14 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 57.130 rev 1, v6.6