Form CDC 57.214 CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summar

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Healthcare Personnel Influenza Vaccination Summary

Page 1 of 2
*required for saving, ^conditionally required for saving
Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked.
*Facility ID#:				^Location:
*Vaccination type: Influenza	*Influenza subtypea: □ Seasonal		*Influenza Seasonb:					Date Last Modified:		__/__/____
			Employee HCP		Non-Employee HCP
			*Employees (staff on facility payroll)		*Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistants		*Adult students/ trainees & volunteers				Other Contract Personnel
1. Number of HCP who worked at this healthcare facility for at least 1 day between October 1 and March 31
2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season
3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season
4. Number of HCP who have a medical contraindication to the influenza vaccine
5. Number of HCP who declined to receive the influenza vaccine
6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above)
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 120 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 (0920-0666).

Healthcare Personnel Influenza Vaccination Summary

Page 2 of 2

Question 1 (Denominator) Notes:

• Include all HCP who have worked at the facility for at least 1 working day during the reporting period, regardless of clinical responsibility or patient contact. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day.

• Include both full-time and part-time persons. If a HCW works in two or more facilities, each facility should include the HCW in their denominator. Count HCP as individuals rather than full-time equivalents.

• Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees.

• The HCP categories are mutually exclusive. Each HCP should be counted only once in the denominator (question 1).

Questions 2-6 (Numerator) Notes:

• Questions 2-6 are mutually exclusive. The sum of the HCP in questions 2-6 should equal the number of HCP in question 1 for each HCP category. Questions 2-6 are to be reported separately for each of the three HCP categories.

• Only the following HCP should be counted in question 4: HCP with (1) a severe allergic reaction to eggs or other vaccine component(s) or (2) a history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination.

• The following should be counted in question 5 (declined to receive influenza vaccine):

  • HCP who declined vaccination because of conditions other than those included in question 4.

  • HCP who declined vaccination and did not provide any other information.

  • HCP who did not receive vaccination because of religious or philosophical exemptions.

  • HCP who deferred vaccination for the entire influenza season (for example, from October 1 through March 31).