57.218 Weekly Vaccination Cumulative Summary for Residents of L

Form Approved

OMB Number: 0920-1317

Expiration Date: 03/31/2026

Weekly Vaccination Cumulative Summary for

Residents of Long-Term Care Facilities (CDC 57.218, Rev 9)

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Facility ID#:
Week of data collection (Monday – Sunday): __/__/____ – __/__/____		Date Last Modified: __/__/____
Cumulative Vaccination Coverage Note: Facilities submit Weekly COVID-19 Vaccination Cumulative Summary data by completing the questions on this form. Facilities also have the option to use the Person-Level Vaccination Forms and select the “view reporting summary and submit” to submit these data. Using Person-Level Vaccination Forms is recommended to ensure that individuals are categorized appropriately according to their vaccination dates. Learn more here: (https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html#anchor_21696)
Total Residents	1. *Number of residents staying in this facility for at least 1 day during the week of data collection
COVID-19 Vaccination	2. *Number of residents in Question #1 who are up to date with COVID-19 vaccines for XX season. Please review the current definition of up to date: Key Terms and Up to Date Vaccination
	Among those not in Question #2, reason not up to date:
	2a. *Medical contraindication to COVID-19 vaccine
	2b. *Offered but declined COVID-19 vaccine
	2c. *Other/unknown COVID-19 vaccination status
Click here to display optional influenza, RSV, and pneumococcal vaccination questions Note: entering these fields is not required to save the form.
Influenza Vaccination	3. *Number of residents in question #1 who are up to date with Influenza vaccination for XX season.
	Among those not in Question #3, reason not up to date:
	3a. *Medical contraindication to COVID-19 vaccine
	3b. *Offered but declined COVID-19 vaccine
	3c. *Other/unknown COVID-19 vaccination status
RSV Vaccination	4. *Number of residents in question #1 who are up to date with RSV vaccination for XX season.
	Among those not in Question #4, reason not up to date:
	4a. *Medical contraindication to COVID-19 vaccine
	4b. *Offered but declined COVID-19 vaccine
	4c. *Other/unknown COVID-19 vaccination status
Pneumococcal Vaccination	5. *Number of residents in question #1 who are up to date with Pneumococcal vaccination
	Among those not in Question #5, reason not up to date:
	5a. *Medical contraindication to COVID-19 vaccine
	5b. *Offered but declined COVID-19 vaccine
	5c. *Other/unknown COVID-19 vaccination status
Adverse Events following Vaccine(s) Clinically significant adverse events should be reported to the Vaccine Adverse Event Reporting System (VAERS) at https://vaers.hhs.gov/reportevent.html. To help identify reports from NHSN sites, please enter your NHSN orgID in Box 26 of the VAERS form. Clinically significant adverse events include vaccine administration errors and serious adverse events (such as death, life-threatening conditions, or inpatient hospitalization) that occur after vaccination, even if it is not certain that vaccination caused the event. Other clinically significant adverse events may be described in the provider emergency use authorization (EUA) fact sheets or prescribing information for the COVID-19 vaccine(s). Healthcare providers should comply with VAERS reporting requirements described in EUAs or prescribing information.
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)). CDC 57.218, Rev 9 Public reporting burden of this collection of information is estimated to average 35 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 Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1317