Form 57.221 Healthcare Personnel COVID-19 Person Level Vaccin

F orm Approved

OMB No. 0920-0666

Exp. Date: 3/31/26

www.cdc.gov/nhsn

57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component (Manual)

Please refer to the table below for complete information on the variables included on manual entry for Person-Level COVID-19 Vaccination Forms for HCP (Healthcare Personnel Safety Component). These are accurate as of NHSN Release 11.5 (September 2023).

Importing via .csv file- Person-Level COVID-19 Vaccination Form- HPS Component
Table 1: NHSN Person-Level COVID-19 Vaccination Form – HPS 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)
hcpid	Required	_	Character (15)	HCP identifier - a unique identifier for the individual, assigned by your facility
gname	Required	_	Character (30)	HCP First Name
surname	Required	_	Character (30)	HCP Last Name
gender	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
ethnicity	Required	HISP NOHISP DEC UNK	Character (6)	HCP Ethnicity HISP – Hispanic or Latino NOHISP – Not Hispanic or Latino DEC – Declined to respond. UNK – Unknown
race	Required	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
vaccLoc	Required	VACCHOSP VACCIPF VACCIRF	_	Vaccination location type VACCHOSP – For data reported for most facility types including acute care hospitals, ambulatory surgery centers, free-standing inpatient psychiatric facilities, free-standing inpatient rehabilitation facilities, long-term acute care hospitals, and dialysis facilities.  This includes all inpatient and outpatient units/departments of the acute care facility sharing the same CCN as the acute care facility VACCIPF – For data reported by a parent facility (often an acute care facility) for an inpatient psychiatric unit with a unique CCN that is mapped as a location of the parent facility. This selection is only available for acute care facilities reporting data for IPF units with a different CCN from the acute care facility.  VACCIRF - For data reported by a parent facility (often an acute care facility) for an inpatient rehabilitation unit with a unique CCN that is mapped as a location of the parent facility. This selection is only available for acute care facilities reporting data for IRF units with a separate CCN from the acute care facility.
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) 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.	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.	COVID2023_2024BIMODERNA 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 (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) 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.	MM/DD/YYYY	Datetime	Dose 2 vaccination date
dose2Mfg	Conditionally required if Dose2Date provided	COVID2023_2024BIMODERNA 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 (addtldosedate)	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, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	MM/DD/YYYY	Datetime	Third dose vaccination date
Dose3Mfg (addtldosemfg)	Conditionally required if dose3Date provided	COVID2023_2024BIMODERNA 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 (boostdose2date)	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, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	MM/DD/YYYY Must be > dose3date	Datetime	Fourth dose vaccination date
Dose4Mfg (boostdose2mfg)	Conditionally required if Dose4Date provided	COVID2023_2024BIMODERNA 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 (boostdose3date)	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, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	MM/DD/YYYY Must be > dose4date	Datetime	Fifth dose vaccination date
Dose5mfg (boostdose3mfg)	Conditionally required if Dose5Date provided	COVID2023_2024BIMODERNA 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 (boostdose4date)	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, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	MM/DD/YYYY Must be > dose5date	Datetime	Sixth dose vaccination date
Dose6mfg (boostdose4mfg)	Conditionally required if Dose6Date provided	COVID2023_2024BIMODERNA 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 (boostdose5date)	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, Moderna COVID-19 vaccine, and Janssen COVID-19 vaccine can only be selected if corresponding dose date is before 9/26/2022. Novavax COVID-19 vaccine can only be selected if corresponding dose date is on or after 6/1/2022.	MM/DD/YYYY Must be > dose6date	Datetime	Seventh dose vaccination date
Dose7mfg (boostdose5mfg)	Conditionally required if Dose6Date provided	COVID2023_2024BIMODERNA 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

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