Healthcare Worker Influenza Vaccination Report

This report is divided into three sections:

I. Facility information

II. Employee healthcare workers

III. Non-employee healthcare workers

Please complete this interim report by January 31, 2013. A full report for the 2012-2013 influenza season will be requested in May, 2013. If you have any questions, write to joseph.wendelken@health.ri.gov

Before submitting this interim report, please make a separate copy of the information to be submitted. A copy of this information will be useful when reporting at the end of influenza season.

Notes

* Questions 1:

• Include all healthcare workers who have worked at the facility since October 1, 2012, regardless of clinical responsibility or patient contact.
• Include both full-timers and part-timers. If a healthcare worker works in two or more facilities, each facility should include the healthcare worker. Count healthcare workers as individuals rather than full-time equivalents.

** Questions 2-5:

• These questions are mutually exclusive. The sum of the numbers submitted for questions 2-5 should equal the number submitted for question 1.