Form 57.215 Seasonal Survey on Influenza Vaccination Programs for He

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Last reviewed March 2020

Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel

Page 1 of 2		*required for saving
Facility ID #: ______________________________
*Date Entered: _________________________		*For Season: ________ - _________
(Month/Year)		(Specify years)
*1. Which personnel groups are included in your facility’s annual influenza vaccination campaign? (check all that apply)
□ Full-time employees
□ Part-time employees
Licensed independent practitioners:
□ Non-employee physicians
□ Non-employee advanced practice nurses
□ Non-employee physician assistants
□ Students and trainees (for example, interns, residents)
□ Adult volunteers □ Other contract personnel
□ Other, specify: ____________________________________
*2. Are healthcare personnel at your facility required to pay out-of-pocket costs for influenza vaccination received at your facility?
□ Yes
□ No
If yes, how much do each of the following groups need to pay for influenza vaccination?
Full-time employees:	$ ______
Part-time employees:	$ ______
Non-employee physicians:	$ ______
Non-employee advanced practice nurses:	$ ______
Non-employee physician assistants:	$ ______
Students and trainees:	$ ______
Adult volunteers:	$ ______
Other contract personnel	$ ______
Other, specify:_____________________________________
*3. Which of the following methods is your facility using this influenza season to deliver vaccine to your healthcare personnel? (check all that apply)
□ Have mobile vaccination carts
□ Provide vaccination in Occupational/Employee Health
□ Provide vaccination in wards, clinics, cafeterias, or common areas
□ Provide vaccination during nights and weekends
□ Provide vaccination at any meetings or grand rounds
□ Provide visible vaccination of any key personnel/leadership
□ Other, specify: _____________________________________
□ None of the above
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 (0920-0666). CDC 57.215 Rev. 1, NHSN v7.1

Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel

Page 2 of 2

*4. Which of the following strategies does your facility use to promote/enhance healthcare personnel influenza vaccination at your facility? (check all that apply)

□ Send vaccination reminders by mail, e-mail, and/or pager

□ Coordinate vaccination with other annual programs (for example, tuberculin skin testing)

□ Require receipt of vaccination for credentialing (if no contraindications)

□ Require receipt of vaccination as a condition of employment

□ Advertise vaccination with a campaign including posters, flyers, buttons, and/or fact sheets

□ Provide education on the benefits and risks of vaccination

□ Track unit-based vaccination rates for some or all units/departments

□ Plan to provide feedback on vaccination rates to facility administration

□ Provide incentives for vaccination

□ Track vaccination on a regular basis for targeting purposes

□ Other, specify: ____________________________________

□ No formal promotional activities are planned

*5. What is your facility’s influenza vaccination policy for healthcare personnel? (check one)

□ Influenza vaccination is required; unvaccinated personnel are terminated from employment

□ Influenza vaccination is required with consequences other than termination for unvaccinated personnel   

□ Influenza vaccination is recommended but not required    

□ My facility does not have a specific influenza vaccination policy for personnel

□ Other, specify: __________________

*6. Which personnel groups are covered by your facility’s influenza vaccination policy? (check all that apply)

□ Full-time employees

□ Part-time employees

Licensed independent practitioners:

□ Non-employee physicians

□ Non-employee advanced practice nurses

□ Non-employee physician assistants

□ Students and trainees (for example, interns, residents)

□ Adult volunteers

□ Other contract personnel

□ Other, specify: __________________

*7. Does your facility require healthcare personnel who receive off-site influenza vaccination to provide documentation of their vaccination status?

□ Yes

□ No

If yes, what type of documentation is acceptable? (check all that apply)

□ Receipt or other proof of purchase from pharmacy or other vaccinator

□ Insurance claim for receipt of influenza vaccination

□ Note from person or organization that administered the vaccination

□ Handwritten statement or e-mail from healthcare worker

□ Signature of healthcare worker on standard facility form attesting to vaccination

□ Other, specify: ____________________________________

*8. What does your facility require from healthcare personnel who refuse influenza vaccination? (check one)

□ Standardized paper or electronic declination form completed by healthcare worker

□ Reading a statement about the risks of non-vaccination (no signature required)

□ Verbal declination of vaccination by healthcare worker

□ Facility does not track vaccine declinations

□ Other, specify: ____________________________________

*9. Does your facility require healthcare personnel who refuse influenza vaccination to wear a mask or other personal

protective equipment (PPE)?

□ Yes

□ No

4-8