Form 0920-0978 FluServ-NET Provider Vaccination History Fax Form

Form approved OMB 0920-0978

Provider Vaccination History Fax Form (for Pediatric Patients)

Date: [current date]
Dear Dr. [LastName]:
The [State/Local Health Department], in collaboration with the Centers for Disease Control and
Prevention, are tracking patients who have been hospitalized with influenza. A patient from your
clinic, Patient Name (DOB: MM/DD/YYYY), was reported to us as having been hospitalized with
influenza beginning on MM-DD-YYYY. We are trying to obtain immunization history on all
hospitalized patients and would appreciate your help in completing the information below for this
patient. If this was not a patient seen by you or another provider at your clinic, please mark
“Unknown” for question 1 or 2 below.
Please fax the completed form to XXX-XXX-XXXX. For any questions, please contact , at
XXX-XXX-XXXX. Thank you in advance for your help.
Investigation of these cases falls within the scope of public health surveillance. The Health Insurance Portability and
Accountability Act (HIPAA) does NOT prohibit your reporting this information to public health authorities (see
http://aspe.hhs.gov/admnsimp/PL104191.htm, Section 1178 (b)).

FOR CHILDREN
1. Did the patient receive influenza vaccine during fall or winter of the current influenza season?
 Yes  No
 Unknown
1a. Indicate the number of doses:  1

2

 Unknown

1b. For each dose, specify the date given (mm-dd-yyyy):
Dose 1: _____ /_____ /_____
Dose 2: _____ /_____ /_____
1c. If patient < 9 years old, specify vaccine type:
 Injected Vaccine
 Nasal Spray/FluMist
 Combination of both

 Unknown Type

2. If patient < 9 years old, did d the patient receive influenza vaccine in any previous seasons?
Yes
 No
 Unknown
To help us complete medical information about your patient, could you please provide us with their
height and weight if this information was obtained within 6 months before their hospitalization?
3. HEIGHT: _________  inches  centimeters 4. WEIGHT: _________  pounds  kilograms
To help us complete the demographic information about your patient, could you please provide us
with their race and ethnicity?
5. Race (check only one):  White

 Black or African American

 American Indian/ Alaska Native

6. Ethnicity (check one):

 Hispanic or Latino

 Multiracial

 Non-Hispanic or Latino

 Asian/Pacific Islander
 Not specified

 Not Specified

Public reporting burden of this collection of information is estimated to average 5 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/ATSDR Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).

APPENDIX D2. Provider Vaccination History Fax Form (for Adult Patients)

Date: [current date]
Dear Dr. [LastName]:
The [State/Local Health Department], in collaboration with the Centers for Disease Control and
Prevention, are tracking patients who have been hospitalized with influenza. A patient from your
clinic, Patient Name (DOB: MM/DD/YYYY), was reported to us as having been hospitalized with
influenza beginning on MM-DD-YYYY. We are trying to obtain immunization history on all
hospitalized patients and would appreciate your help in completing the information below for this
patient. If this was not a patient seen by you or another provider at your clinic, please mark
“Unknown” for question 1 below.
Please fax the completed form to XXX-XXX-XXXX. For any questions, please contact , at
XXX-XXX-XXXX. Thank you in advance for your help.
Investigation of these cases falls within the scope of public health surveillance. The Health Insurance Portability and
Accountability Act (HIPAA) does NOT prohibit your reporting this information to public health authorities (see
http://aspe.hhs.gov/admnsimp/PL104191.htm, Section 1178 (b)).

FOR ADULTS
1. Did the patient receive influenza vaccine during fall or winter of the current influenza season?
 Yes
 No
 Unknown
1a. If yes, specify the date given (mm-dd-yyyy): _____ /_____ /_____
To help us complete medical information about your patient, could you please provide us with their
height and weight if this information was obtained within 6 months before their hospitalization?
2. HEIGHT: _________  inches  centimeters 3. WEIGHT: _________  pounds  kilograms
To help us complete the demographic information about your patient, could you please provide us
with their race and ethnicity?
5. Race (check only one):  White

 Black or African American

 American Indian/ Alaska Native

6. Ethnicity (check one):

 Hispanic or Latino

 Multiracial

 Non-Hispanic or Latino

 Asian/Pacific Islander
 Not specified

 Not Specified