Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary fo

Form Approved

OMB No. 0920-1317

Exp. Date: 3/31/26

www.cdc.gov/nhsn

June 2023

Weekly COVID-19 Vaccination Cumulative Summary for

Dialysis Patients (CDC 57.509, Rev 7)

	2 pages *required for saving
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 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 patients 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
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)). 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 (0920-1317). CDC 57.509, Rev 7

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