This Hospital Name/Logo
Infection Prevention Healthcare Personnel Influenza Vaccination Reporting Process Form
NOTE TO HOSPITALS: This Form contains PHI, and should be treated accordingly when considering means
of return to department accountable for reporting information to CMS via NHSN.
Dear [Hospital Employee]:
[This Hospital Name] is required by the Centers for Medicare & Medicaid Services (CMS) to report
information regarding influenza vaccination in our facility. All employees, licensed independent
practitioners, adult volunteers and students working in [This Hospital Name] for at least one day during the
reporting period, (October 1 through March 31) must complete this form. All information below must be
completed on this form and returned to [which hospital department] via [ means to return form] and
returned by [date/how many days after hire date, etc.].
_______________________________
Date form completed
___________________________________
___________________
____________________
Name of Employee/LIP/Volunteer/Student
Date of Birth
Date of Hire
Please check your appropriate status:
_____Employee
_____Licensed Independent Practitioner
____ Volunteer
____ Student
Please check all statements below that indicate accurate information for the above-named individual:
1. _____I have already received an influenza vaccination for the current flu season from [This
Hospital Name].
2. _____ I plan to receive an influenza vaccination for the current flu season from [This Hospital
Name] as soon as vaccination program becomes available.
3. _____ I received an influenza vaccination from __________________________(name source) on
_________________(date received). Please attach documentation of receipt of vaccination. Verbal
statements are not acceptable.
4. _____I am declining to receive an influenza vaccination for the current flu season. Please attach
signed declination form designating reason (other than medical contraindication) for declination of
vaccine
5. _____ I have a documented medical contraindication and cannot receive influenza vaccine for the
following reason:___________________________________________________________. Please
attach documentation of medical contraindication as indicated by hospital policy.
The above-named individual attests to the accuracy of the information given on this form by legibly printing
and signing name below.
___________________________________
Printed Name
_________________________________
Signed Name
Form Completion: Indications and Directions for Hospitals
Hospitals may customize this form, created in Microsoft Word, for their own use. It is recommended that
the hospital Human Resources Department, the Medical Staff Credentialing Department and any other
departments overseeing the governance of students and volunteers within the facility issue this form to all
required healthcare personnel in the CDC-defined denominator categories (see below) upon hire, along
with or attached to the hospital’s current employee influenza immunization policy. The required healthcare
personnel in question must be physically present in the healthcare facility for at least one working day
during the reporting period, which is October 1 through March 31. Working any number of hours during a
day serves as one working day. This will serve to communicate to the required healthcare personnel as
listed below, and will also serve to assist all departments involved in collecting the required denominator
information for reporting.
The required numerator categories are included on the form, and include those vaccinated at the
healthcare facility, those vaccinated elsewhere (it is noted this year that verbal accounting for this is not
acceptable, so documentation must be available), those declining and those with medical
contraindications (medical contraindications are defined in the CDC instructions, and verbal statements for
medical contraindications are acceptable according to CDC; however, hospital policy may vary). The
remaining numerator category is for those with unknown status at the end of the reporting period.
These numbers must add up at the end of the reporting period in order to save the data in NHSN for
reporting to CMS.
The required healthcare personnel to be counted in this reporting are:
1. Employee: defined as all persons receiving a direct paycheck from the healthcare facility (i.e., on
facility’s payroll) regardless of clinical responsibility or patient contact. This would include full-time,
part-time and PRN employees who receive a paycheck from the facility.
2. Licensed independent practitioner: defined as physicians (MD, DO); advanced practice nurses; and
physician assistants only who are affiliated with the healthcare facility, but are not directly employed by
it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient
contact. Post-residency fellows are also included in this category. Advanced practice nurses include:
nurse practitioners, nurse midwives, clinical nurse specialists and nurse anesthetists.
3. Adult student/trainee or volunteer: defined as medical, nursing or other health professional students,
interns, medical residents or volunteers aged 18 or older that are affiliated with the healthcare facility,
but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of
clinical responsibility or patient contact.
A fourth category of healthcare personnel may be optionally reported. This is the category of non-employee
contract personnel. Contract personnel are defined as persons providing care, treatment or services at the
facility through a contract who do not fall into any of the other denominator categories. Some examples
include nurses (through agency and travel employers), dialysis technicians, occupational therapists,
admitting staff and housekeeping/environmental services staff. Nurses who are not advanced practice
nurses should be included in this category. However, it is important to remember that non-employee
physicians and advanced practice nurses, and contract ED physicians are always counted as licensed
independent practitioners even if they are paid through a contract. You can refer to Appendix A of the HCP
Influenza Vaccination Summary Protocol for a suggested list of contract personnel found at this link:
www.cdc.gov/nhsn/acute-care-hospital/hcp-vaccination/index.html#pro
All material presented or referenced herein is intended for general purposes and is not intended to provide or replace
the independent judgment of a qualified healthcare provider treating a particular patient. Ohio KePRO disclaims any
representation or warranty with respect to treatments or course of treatment based upon information provided.
Publication No. 311201-OH-2150-11/2013. This material was provided by Alliant GMCF, the Medicare Quality
Improvement Organization for Georgia, and was prepared by Ohio KePRO, the Medicare Quality Improvement
Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.