Healthcare Worker Influenza Vaccination Report

This report is used to measure the influenza vaccination rates of healthcare workers in facilities throughout Rhode Island. Certain healthcare facilities are required to report vaccination information about their healthcare workers (both employees and non-employees). They are:

  • Adult Day Care (ADC)
  • Ambulatory Surgery Center (PHS)
  • Freestanding Ambulatory Surgical Center (FAS)
  • Freestanding Emergency Care Facility (FEC)
  • Home Care Provider (HCP)
  • Home Nursing Care Provider (HNC)
  • Hospice (HSP)
  • Hospital (HOS) (Each hospital should include workers at all premises)
  • Kidney Disease Treatment (KDT)
  • Nursing Facility (LTC)
  • Nursing Service Agency (NPA)
  • Organized Ambulatory Care Facility (ACF)

Facilities whose license number begins with the above abbreviations must report vaccination information. (Facility types not included in this list do not have to report.) A healthcare facility that has multiple sites, each with a different license number, should report separately.

Please complete this report each influenza season by May 15. If you have any questions, please contact Hanna Kim at 222-1961.

This report is divided into three sections:

I. Facility information

II. Employee healthcare workers

III. Non-employee healthcare workers

Please use the "Tab" or "Cursor" to move to the next field in the form.

I. Facility Information
  • Valid license number will populate the Facility Name and Type.
  • Pulled from License Number
  • Pulled from License Number

II. Employee healthcare workers

Employee healthcare workers are staff on the facility's payroll. Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees.

NOTES:

  • Include all healthcare workers who have worked at the facility for at least 1 working day from October 1 through March 31, 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.

III. Non-employee healthcare workers

For this report, non-employee healthcare workers are either: a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants), or b. Adult students/trainees and volunteers. Enter zeros in fields that do not apply to your facility.

NOTES:

  • Licensed independent practitioners who fit the criteria for the Employee healthcare worker section and are counted in that section should not be counted in the Non-employee healthcare worker section.
  • Include all non-employee healthcare workers who have worked at the facility for at least 1 working day from October 1 through March 31, regardless of clinical responsibility or patient contact.
  • Include both full-timers and part-timers. If a non-employee healthcare worker works in two or more facilities, each facility should include the non-employee healthcare worker. Count non-employee healthcare workers as individuals rather than full-time equivalents.

  • a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants) This value should equal the total from questions 2a, 3a, 4a, and 5a.(1a= 2a + 3a + 4a + 5a)
    b. Adult students/trainees and volunteers This value should equal the total from questions 2b, 3b, 4b, and 5b. (1b= 2b + 3b + 4b + 5b)
  • a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants)
    b. Adult students/trainees and volunteers
  • a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants)
    b. Adult students/trainees and volunteers
  • a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants)
    b. Adult students/trainees and volunteers
  • a. Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants)
    b. Adult students/trainees and volunteers

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