Healthcare Worker Influenza Vaccination and Declination Survey 2012-2013 LONG FORM

2011-2012 Healthcare Worker Influenza Vaccination Survey

Healthcare facilities are required to report influenza vaccination, documented contraindication, and informed declination rates for staff in accordance with ORS 442.851, Notes Following, and OARs 409-023-0000 through 409-023-035. The Oregon Health Authority, Office for Oregon Health Policy and Research, notified facilities of this reporting requirement in September 2011.

This required survey for the 2012-2013 flu season is due May 20, 2013.

Questions 1 through 6 of this survey are identical to Questions 1 through 6 of the annual Flu Summary module in the National Healthcare Safety Network (NHSN) Healthcare Personnel Safety Component. If your facility is required by the Centers for Medicare and Medicaid Services (CMS) to complete the NHSN survey for this season, you do not need to double-enter these data; please use to answer three required supplementary questions on your facility's vaccine delivery and promotion methods for this season.

Consistent with the NHSN survey, we are collecting vaccination data for three categories of healthcare workers: (1) employees, i.e., staff on facility payroll); (2) licensed independent practitioners, i.e., physicians, advanced practice nurses, & physician assistants; and (3) adult students/trainees and volunteers. The survey requires documentation of the total number of healthcare personnel at your facility in each of these three categories (denominator counts) as well as the number in each category who received, declined, or had a medical contraindication to influenza vaccine. Counts and vaccination/declination rates of other contract personnel at your facility are optional.

If you have any questions regarding this survey, contact Valerie Ocampo at or 971-673-1111.

Zintars Beldavs
Manager, Healthcare-Associated Infections Program
Center for Public Health Practice
Public Health Division, Oregon Health Authority