Healthcare Worker Influenza Vaccination - NHSN
Form Template
This Healthcare Worker Influenza Vaccination is used to collect specific information on whether a seasonal and/or non-seasonal influenza vaccination was received or declined by the HCW, and the date, time, location and type of vaccination that was administered.
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A separate form is required for each dose of vaccine. The form also contains information on any adverse reactions experienced as a result of the vaccine. This form should be completed for all HCP.
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