Form 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-L

Form Approved

OMB No. 0920-1317

Exp. Date: 3/31/26

www.cdc.gov/nhsn

57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Long-Term Care Component (Manual)

Please refer to the tables below for complete information on the variables included in manual entry for Person-Level COVID-19 Vaccination Forms for Residents and Healthcare Personnel (Long-term Care Facility Component). Variables are listed on pages 17-28 for this measure. These are updated as of April 2024. Please note that if a field name has a parenthetical value, this is an alias and upload with either the field name or its alias will result in successful file transmission.

Importing via .csv file Person-Level COVID-19 Vaccination Form- Residents - LTC Component
Table 1: NHSN Person-Level COVID-19 Vaccination Form- Residents Import File Format
Field (alias, applicable)	Requirement	Values	Format	Description of Field
orgID	Required	-	must be a whole number	Must be a valid NHSN Facility ID (organization identifier)
resID	Required	-	Character (15)	Resident identifier - a unique identifier for the individual, assigned by your facility
dob	Required	MM/DD/YYYY	Datetime	Resident Date of Birth
Resgender	Required for all records beginning 10/24/2022	F M O	Character (1)	Resident Gender F – Female M – Male O – Other/Unknown
resethnicity	Required for all records beginning 10/24/2022	HISP NOHISP DEC UNK	Character (6)	Resident Ethnicity HISP – Hispanic or Latino NOHISP – Not Hispanic or Latino DEC – Declined to respond UNK – Unknown
resrace	Required for all records beginning 10/24/2022	AMIN ASIAN AAB NH-PI WHITE DEC UNK	Character	Resident Race: AMIN – American Indian/Alaskan native ASIAN – Asian AAB – Black or African American NH-PI Native Hawaiian/Other Pacific Islander WHITE – White DEC – Declined to respond UNK- Unknown
resAdmitDate	Required	MM/DD/YYYY	Datetime	Resident Admit Date
resDischDate	Conditionally required	MM/DD/YYYY Must be >= resAdmitDate	Datetime	Resident Discharge Date
resGName	Required	-	Character (30)	Resident First Name
resSurname	Required	-	Character (30)	Resident Last Name
dose1Date	Conditionally required (each record must contain At least ONE status- This means each record must be classified into at least one of the main categories, such as having at least one vaccine entered, contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Dose 1 vaccination date
dose1Mfg	Conditionally required if Dose1Date provided. If dose1Mfg = Janssen, then enter subsequent doses beginning with the dose 3 fields. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 4/20/2023 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine can only be selected if corresponding dose date is on or before 4/19/2023. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022. Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 6/26/2023.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Dose 1 vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
dose2Date	Conditionally required.	MM/DD/YYYY Must be > Dose1Date	Datetime	Dose 2 vaccination date
dose2Mfg	Conditionally required if Dose2Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 4/20/2023 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine can only be selected if corresponding dose date is on or before 4/19/2023. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022. Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 6/26/2023.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Dose 2 vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
medDate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such as bivalent vaccination, contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Contraindication or exclusion noted date
decDate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such as bivalent vaccination, contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Declination date
decReason	Conditionally required if decDate provided	RELIGIOUS OTHER UNKNOWN	Character (10)	Declination reason: RELIGIOUS - Received official religious exemption OTHER - Other UNKNOWN - Unknown
unkvaccstatusdate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such as bivalent vaccination, contraindication, declined, unknown vaccination status)	MM/DD/YYYY	Datetime	Unknown status date
Dose3date	Conditionally required.	MM/DD/YYYY Must be > Dose2Date	Datetime	Third dose vaccination date
dose3type	Conditionally required if dose date is <6/26/2023	BOOST ADDTL	Character (5)	Type of third dose vaccine received: BOOST – Booster Dose ADDTL – Additional Dose
Dose3Mfg	Conditionally required if dose3Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen COVID-19 vaccine can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Third dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose4Date	Conditionally required.	MM/DD/YYYY Must be > dose3date	Datetime	Fourth dose vaccination date
Dose4Mfg	Conditionally required if Dose4Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Fourth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose5Date	Conditionally required.	MM/DD/YYYY Must be > dose4date	Datetime	Fifth dose vaccination date
Dose5Mfg	Conditionally required if Dose5Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Fifth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose6Date	Conditionally required.	MM/DD/YYYY Must be > Dose5Date	Datetime	Sixth dose vaccination date
Dose6Mfg	Conditionally required if Dose6Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Sixth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose7Date	Conditionally required.	MM/DD/YYYY Must be > Dose6Date	Datetime	Seventh dose vaccination date
Dose7Mfg	Conditionally required. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Seventh dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose8Date	Conditionally required.	MM/DD/YYYY Must be > Dose7Date	Datetime	Eighth dose vaccination date
Dose8Mfg	Conditionally required. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023.	COVID2023_2024 UNSPECIFIED	Character (15)	Eighth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine UNSPECIFIED – unknown manufacturer
Dose9Date	Conditionally required.	MM/DD/YYYY Must be > Dose8Date	Datetime	Ninth dose vaccination date
Dose9Mfg	Conditionally required. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023.	COVID2023_2024 UNSPECIFIED	Character (15)	Ninth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine UNSPECIFIED – unknown manufacturer
Dose10Date	Conditionally required.	MM/DD/YYYY Must be > Dose9Date	Datetime	Tenth dose vaccination date
Dose10Mfg	Conditionally required. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023.	COVID2023_2024 UNSPECIFIED	Character (15)	Tenth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine UNSPECIFIED – unknown manufacturer
dose1NDC	Optional	-	Character (30)	Dose 1 vaccine NDC number
dose1Lot	Optional	-	Character (30)	Dose 1 vaccine Lot number
dose1ExpDate	Optional	MM/DD/YYYY	Datetime	Dose 1 vaccine expiration date
dose2NDC	Optional	-	Character (30)	Dose 2 vaccine NDC number
dose2Lot	Optional	-	Character (30)	Dose 2 vaccine Lot number
dose2ExpDate	Optional	MM/DD/YYYY	Datetime	Dose 2 vaccine expiration date
dose3ndc (addtldosendc)	Optional	-	Character (30)	Third dose vaccine NDC number
dose3lot (addtldoselot)	Optional	-	Character (30)	Third dose vaccine Lot number
dose3expdate (addtldoseexpdate)	Optional	MM/DD/YYYY	Datetime	Third dose expiration date
dose4ndc (boostdose2ndc)	Optional	-	Character (30)	Fourth dose NDC number
dose4lot (boostdose2lot)	Optional	-	Character (30)	Fourth dose vaccine Lot number
dose4expdate (boostdose2expdate)	Optional	MM/DD/YYYY	Datetime	Fourth dose vaccine expiration date
dose5ndc (boostdose3ndc)	Optional	-	Character (30)	Fifth dose NDC number
dose5lot (boostdose3lot)	Optional	-	Character (30)	Fifth dose vaccine Lot number
dose5expdate (boostdose3expdate)	Optional	MM/DD/YYYY	Datetime	Fifth dose vaccine expiration date
dose6ndc (boostdose4ndc)	Optional	-	Character (30)	Sixth dose NDC number
dose6lot (boostdose4lot)	Optional	-	Character (30)	Sixth dose vaccine Lot number
dose6expdate (boostdose4expdate)	Optional	MM/DD/YYYY	Datetime	Sixth dose vaccine expiration date
dose7ndc (boostdose5ndc)	Optional	-	Character (30)	Seventh dose vaccine NDC number
dose7lot (boostdose5ndc)	Optional	-	Character (30)	Seventh dose vaccine Lot number
dose7expdate (boostdose5expdate)	Optional	MM/DD/YYYY	Datetime	Seventh dose vaccine expiration date
dose8ndc	Optional	-	Character (30)	Eighth dose vaccine NDC number
dose8lot	Optional	-	Character (30)	Eighth dose vaccine Lot number
dose8expdate	Optional	MM/DD/YYYY	Datetime	Eighth dose vaccine expiration date
dose9ndc	Optional	-	Character (30)	Ninth dose vaccine NDC number
dose9lot	Optional	-	Character (30)	Ninth dose vaccine Lot number
dose9expdate	Optional	MM/DD/YYYY	Datetime	Ninth dose vaccine expiration date
Dose10ndc	Optional	-	Character (30)	Tenth dose vaccine NDC number
Dose10lot	Optional	-	Character (30)	Tenth dose vaccine Lot number
Dose10expdate	Optional	MM/DD/YYYY	Datetime	Tenth dose vaccine expiration date
vaccElsewhere	Optional	Y N	Character (1)	Vaccinated at another location? Y for Yes N for No
vaccEdDate	Optional	MM/DD/YYYY	Datetime	Vaccination Education Provided - date
comment	Optional	-	Character (2000)	Comments

Importing via .csv file- Person-Level COVID-19 Vaccination Form- HCP - LTC Component
Table 2: NHSN Person-Level COVID-19 Vaccination Form – HCP Import File Format
Field (alias if applicable)	Requirement	Values	Format†	Description of Field
Orgid	Required	_	must be a whole number	Must be a valid NHSN Facility ID (organization identifier)
staffid	Required	_	Character (15)	HCP identifier - a unique identifier for the individual, assigned by your facility
hcpgname	Required	_	Character (30)	HCP First Name
hcpsurname	Required	_	Character (30)	HCP Last Name
hcpgender	Required	F M O	Character (1)	HCP Gender F – Female M – Male O – Other/Unknown
dob	Required	MM/DD/YYYY	Datetime	HCP Date of Birth
hcpethnicity	Required	HISP NOHISP DEC UNK	Character (6)	HCP Ethnicity HISP – Hispanic or Latino NOHISP – Not Hispanic or Latino DEC – Declined to respond. UNK – Unknown
hcprace	Required Multi-select	AMIN ASIAN AAB NH-PI WHITE DEC UNK	Character (5)	HCP Race: AMIN – American Indian/Alaskan native ASIAN – Asian AAB – Black or African American NH-PI – Native Hawaiian/Other Pacific Islander WHITE – White DEC – Declined to respond. UNK- Unknown
hcpEmpStart	Required	MM/DD/YYYY	Datetime	HCP Start of Employment Date
hcpEmpEnd	Conditionally required	MM/DD/YYYY	Datetime	HCP End of Employment Date
hcpCategory	Required	EMP LIP VOL OCP	Character (10)	HCP Category: EMP - Employees (staff on facility payroll) LIP - Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistants VOL - Adult students/trainees & volunteers OCP - Other Contract Personnel
dose1Date	Conditionally required (each record must contain At least ONE status- This means each record must be classified into at least one of the main categories, such as having at least one vaccine entered, contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Dose 1 vaccination date
dose1Mfg	Conditionally required if Dose1Date provided If dose1Mfg = Janssen, then subsequent doses recorded beginning with dose 3 fields. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 4/20/2023 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine can only be selected if corresponding dose date is on or before 4/19/2023. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022. Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 6/26/2023.	COVID2023_2024 BIMODERNA BIPFIZBION JANSSEN MODERNA PFIZBION NOVAVAX UNSPECIFIED	Character (15)	Dose 1 vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
dose2Date	Conditionally required.	MM/DD/YYYY	Datetime	Dose 2 vaccination date
dose2Mfg	Conditionally required if Dose2Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 4/20/2023 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine can only be selected if corresponding dose date is on or before 4/19/2023. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022. Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 6/26/2023.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Dose 2 vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
medDate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such having at least one vaccine entered, contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Contraindication or exclusion noted date
decDate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such as having at least one vaccine entered , contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Declination date
decReason	Conditionally required if decDate provided.	RELIGIOUS OTHER UNKNOWN	Character (10)	Declination reason: RELIGIOUS - Received official religious exemption OTHER - Other UNKNOWN - Unknown
unkvaccstatusdate	Conditionally required (each record must contain At least ONE status- This means each record much be classified into at least one of the main categories, such as having at least one vaccine entered , contraindication, declined, unknown vaccination status).	MM/DD/YYYY	Datetime	Unknown status date
Dose3date	Conditionally required.	MM/DD/YYYY	Datetime	Third dose vaccination date
dose3type	Required if dose date is <6/26/2023	BOOST ADDTL	Character (5)	Type of additional or booster dose vaccine received: BOOST – Booster Dose ADDTL – Additional Dose
Dose3Mfg	Conditionally required if dose3Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Third dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose4Date	Conditionally required.	MM/DD/YYYY Must be > dose3date	Datetime	Fourth dose vaccination date
Dose4Mfg	Conditionally required if Dose4Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Fourth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose5Date	Conditionally required.	MM/DD/YYYY Must be > dose4date	Datetime	Fifth dose vaccination date
Dose5mfg	Conditionally required if Dose5Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Fifth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose6Date	Conditionally required.	MM/DD/YYYY Must be > dose5date	Datetime	Sixth dose vaccination date
Dose6mfg	Conditionally required if Dose6Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Sixth dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
Dose7Date	Conditionally required.	MM/DD/YYYY Must be > dose6date	Datetime	Seventh dose vaccination date
Dose7mfg	Conditionally required if Dose7Date provided. 2023-2024 Updated COVID-19 vaccine can only be selected if corresponding dose date is after 9/12/2023. Bivalent Pfizer vaccine and Bivalent Moderna vaccine can only be selected if corresponding dose date is between 8/31/2022 and 9/12/2023. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine and Janssen can only be selected if corresponding dose date is on or before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	COVID2023_2024 BIMODERNA BIPFIZBION MODERNA PFIZBION NOVAVAX JANSSEN UNSPECIFIED	Character (15)	Seventh dose vaccine manufacturer name COVID2023_2024 –2023-2024 updated vaccine BIMODERNA –bivalent Moderna vaccine BIPFIZBION –bivalent Pfizer vaccine MODERNA – original monovalent Moderna vaccine PFIZBION – original monovalent Pfizer vaccine JANSSEN – original monovalent Janssen vaccine UNSPECIFIED – unknown manufacturer
dose1NDC	Optional	-	Character (30)	Dose 1 vaccine NDC number
dose1Lot	Optional	-	Character (30)	Dose 1 vaccine Lot number
dose1ExpDate	Optional	MM/DD/YYYY	Datetime	Dose 1 vaccine expiration date
dose2NDC	Optional	-	Character (30)	Dose 2 vaccine NDC number
dose2Lot	Optional	-	Character (30)	Dose 2 vaccine Lot number
dose2ExpDate	Optional	MM/DD/YYYY	Datetime	Dose 2 vaccine expiration date
dose3NDC (addtldosendc)	Optional	-	Character (30)	Third dose vaccine NDC number
dose3Lot (addtldoselot)	Optional	-	Character (30)	Third dose vaccine Lot number
dose3ExpDate (addtldoseexpdate)	Optional	MM/DD/YYYY	Datetime	Third dose vaccine expiration date
dose4ndc (boostdose2ndc)	Optional	-	Character (30)	Fourth dose vaccine NDC number
dose4lot (boostdose2lot)	Optional	-	Character (30)	Fourth dose vaccine Lot number
dose4expdate (boostdose2expdate)	Optional	MM/DD/YYYY	Datetime	Fourth dose expiration date
dose5ndc (boostdose3ndc)	Optional	-	Character (30)	Fifth dose vaccine NDC number
dose5lot (boostdose3lot)	Optional	-	Character (30)	Fifth dose vaccine Lot number
dose5expdate (boostdose3expdate)	Optional	MM/DD/YYYY	Datetime	Fifth dose vaccine expiration date
Dose6ndc (boostdose4ndc)	Optional	-	Character (30)	Sixth dose vaccine NDC number
Dose6lot (boostdose4lot)	Optional	-	Character (30)	Sixth dose vaccine Lot number
Dose6expdate (boostdose4expdate)	Optional	MM/DD/YYYY	Datetime	Sixth dose vaccine expiration date
Dose7ndc (boostdose5ndc)	Optional	-	Character (30)	Seventh dose vaccine NDC number
Dose7lot (boostdose5lot)	Optional	-	Character (30)	Seventh dose vaccine Lot number
Dose7expdate (boostdose5expdate)	Optional	MM/DD/YYYY	Datetime	Seventh dose vaccine expiration date
vaccElsewhere	Optional	Y N	Character (1)	Vaccinated at another location? Y – Yes N – No
vaccEdDate	Optional	MM/DD/YYYY	Datetime	Vaccination Education Provided - date
comment	Optional	-	Character (2000)	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 60 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 (0920-1317).