Form Information only

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Healthcare Personnel Influenza Vaccination Cumulative Summary

for Non-Long-Term Care Facilities (CDC 57.211, Rev 2)

2 Pages
*required for saving, ^conditionally required for saving
*Facility ID#:				^Location:
*Vaccination type: Influenza	*Influenza subtypea: □ Seasonal		*Influenza Seasonb:
Week of data collection (Monday – Sunday): __/__/____ – __/__/____						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 that were eligible to have worked at this healthcare facility for at least 1 day during the week of data collection
2. Cumulative number of HCP in question #1 that received an influenza vaccination at this healthcare facility since influenza vaccine became available this season
3. Cumulative number of HCP in question #1 that provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season
4. Number of HCP in question #1 that have a medical contraindication to the influenza vaccine
5. Number of HCP in question #1 that declined to receive the influenza vaccine this season
6. Number of HCP in question #1 with unknown vaccination status (or criteria not met for questions #2-#5 above)
Vaccine Availability
7. Has your facility received its supply of influenza vaccine for the current influenza season? [Yes, or Only a portion of the supply was received, or No]
8. Is your facility currently experiencing a shortage of influenza vaccine for the current influenza season? [Yes or No]
Custom Fields
Label				Label
_________________________		____/____/_____		_________________________				____/____/_____
_________________________		______________		_________________________				______________
_________________________		______________		_________________________				______________
_________________________		______________		_________________________				______________
_________________________		______________		_________________________				______________
_________________________		______________		_________________________				______________
Comments
a For the purposes of NHSN, influenza subtype refers to whether seasonal or non-seasonal vaccine is used. Seasonal is the default and only current choice. b For the purposes of NHSN, an influenza season is defined as July 1 to June 30. 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 25 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).

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Last reviewed November 2020