Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialy

September 2021

Weekly COVID-19 Vaccination Cumulative Summary for

Dialysis Patients (CDC 57.509, Rev 4)

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Facility ID # (OrgID#):			Facility CCN #:
Facility name:
Vaccination type: COVID-19
Week of data collection (Wednesday – Tuesday):		Date last modified: __/__/____
Cumulative Vaccination Coverage
	*All Patients (Total)			In-Center Dialysis Patients	Home Dialysis Patients
1. *Number of patients receiving dialysis care from this facility during the current reporting week
2. *Cumulative number of patients in Question #1 who have received COVID-19 vaccine(s) at this facility or elsewhere since December 2020:
2.1. Only dose 1 of Pfizer-BioNTech COVID-19 vaccine
2.2. Dose 1 and dose 2 of Pfizer-BioNTech COVID-19 vaccine
2.3. Only dose 1 of Moderna COVID-19 vaccine
2.4. Dose 1 and dose 2 of Moderna COVID-19 vaccine
2.5. Dose of Janssen COVID-19 vaccine
2.99. Complete COVID-19 vaccination series: unspecified manufacturer
Any completed COVID-19 vaccination series
	*All Patients (Total)			In-Center Hemodialysis Patients	Home Dialysis Patients
3. Cumulative number of patients in Question #1 with other conditions:
3.1 *Medical contraindication or exclusions to COVID-19 vaccine
3.2. *Offered but declined COVID-19 vaccine
3.3. *Unknown COVID-19 vaccination status
4. *Cumulative number of patients in question #2 eligible to receive an additional dose or booster of COVID-19 vaccine
5. *Cumulative number of patients in question #4 who have received an additional dose or booster of COVID-19 vaccine at this facility or elsewhere since August 2021
5.1. *Additional dose or booster of Pfizer-BioNTech COVID-19 vaccine
5.2. * Additional dose or booster of Moderna COVID-19 vaccine
5.3 * Additional dose or booster of Janssen COVID-19 vaccine
5.4. Additional dose or booster of unspecified manufacturer
* Any Additional dose or booster of COVID-19 vaccine series
COVID-19 Vaccine(s) Supply Please contact your state or local health jurisdiction if there is insufficient supply of COVID-19 vaccine or if your facility is interested in becoming a COVID-19 vaccination provider.
*6. For the current reporting week, please describe the availability of COVID-19 vaccine(s) for patients receiving dialysis from your facility: 6.1 Is your facility enrolled as a COVID-19 vaccination provider? [Select Yes or No] 6.2. Did your facility have a sufficient supply of COVID-19 vaccine(s) to offer all patients the opportunity to receive COVID-19 vaccine(s) from your facility in the current reporting week? [Select Yes or No] 6.3. Did your facility have other arrangements sufficient to offer all patients the opportunity to receive COVID-19 vaccine(s) in the current reporting week (examples of other arrangements include referring to the health department or pharmacies for vaccination)? [Select Yes or No] 6.4. Please describe any other COVID-19 vaccination supply-related issue(s) at your facility. [Optional]
Reminder for reporting to Vaccine Adverse Event Reporting System (VAERS) Please note that clinically significant adverse events following COVID-19 vaccination 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 57.509, Rev 4

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