0920-1317 Healthcare Personnel COVID-19 Vaccination Cumulative Sum

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Healthcare Personnel COVID-19 Vaccination Cumulative Summary

(CDC 57.219, Rev 9)

(Note: This form is used for the Long-term Care Facility and Healthcare Personnel Safety Components.)

		2 Pages
		*required for saving
*Facility ID#:
*Vaccination type: COVID-19
*Week of data collection (Monday – Sunday): __/__/____ – __/__/____					*Date Last Modified: __/__/____
Cumulative Vaccination Coverage
		Healthcare Personnel (HCP) Categories
		All Core HCPa	All HCPb	Employee HCP	Non-Employee HCP
				*Employees (staff on facility payroll)c	*Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistantsd	*Adult students/ trainees & volunteerse	*Other Contract Personnelf
1. *Number of HCP that were eligible to have worked at this healthcare facility for at least 1 day during the week of data collection
2. *Cumulative number of HCP in Question #1 who are up to date with COVID-19 vaccines. Please review the current definition of up to date: Key Terms and Up to Date Vaccination
3. *Cumulative number of HCP in Question #1 with other conditions:
3.1. *Medical contraindication to COVID-19 vaccine
3.2. *Offered but declined COVID-19 vaccine
3.3. *Unknown/other COVID-19 vaccination status
a. Sum of Employees (staff on facility payroll), Licensed independent practitioners: Physicians, advanced practice nurses & physician assistants, and Adult students/trainees & volunteers. b. Sum of Employees (staff on facility payroll), Licensed independent practitioners: Physicians, advanced practice nurses & physician assistants, Adult students/trainees & volunteers, and Other contract personnel. c. All persons receiving a direct paycheck from the healthcare facility (i.e., on the facility’s payroll), regardless of clinical responsibility or patient contact. d. Physicians (MD, DO); advanced practice nurses; and physician assistants only who are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category. e. Adult students/trainees and volunteers: medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older that are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. f. Persons providing care, treatment, or services at the facility through a contract who do not fall into any other HCP (denominator) categories.
Adverse Events following COVID-19 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.

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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 45 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666). CDC 57.128 v.10 September 2024