Form CDC 57.506 CDC 57.506 Dialysis Patient Influenza Vaccination Denominator

[NCEZID] The National Healthcare Safety Network (NHSN)

57.506_DIAL Patient Flu Vacc Denom_BLANK

57.506 Dialysis Patient Influenza Vaccination Denominator

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn


Dialysis Patient Influenza Vaccination Denominator


Page 1 of 1

*required for saving

*Facility ID#

*Month:

*Year:

*Vaccination type: Influenza

*Influenza subtype:

Seasonal

Non-Seasonal





*In-center hemodialysis

*Home hemodialysis

*Peritoneal dialysis

Number of Patients:

Instructions:

  • For the FIRST MONTH of your vaccination campaign, report the total patient census.

  • In SUBSEQUENT MONTHS of your vaccination campaign, report only new patients.

(Only include patients 6 months or older.)





Custom Fields

Label

Label

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Comments






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 57.506 rev 1, v 8.1


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AuthorAmy Schneider
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