Form CDC 57.506 CDC 57.506 Dialysis Patient Influenza Vaccination Denominator

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
_______________________	____/____/_________			_______________________				____/____/_________
_______________________	____/____/_________			_______________________				____/____/_________
_______________________	____/____/_________			_______________________				____/____/_________
_______________________	____/____/_________			_______________________				____/____/_________
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