Healthcare Worker Influenza Vaccination Report

This report is used by the Department of Health to determine the vaccination rates of healthcare workers in facilities throughout Rhode Island. Only healthcare facility administators who have been contacted about this report need to complete this report.

Healthcare facility administrators who have been contacted about this report are asked to complete it by May 31, 2013. This report is divided into three sections:

I. Facility information

II. Employee healthcare workers

III. Non-employee healthcare workers

If you have any questions, write to immunization@health.ri.gov

Before submitting this interim report, please make a separate copy of the information to be submitted.

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.