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Healthcare Worker Influenza Vaccination Program
Reporting Form
Thank you for taking an interest in telling us about your successful program to vaccinate your organization's healthcare workers against influenza.

The purpose of this form is to gather a broad range of examples of programs that have been particularly effective in increasing influenza vaccination rates of healthcare workers. We will not make public any of the information you report here, without your permission. Items in orange are required.
 
Contact Information
Your first name:
Your last name:
Organization name:
Street1:
Street2:
City:
State or Province:
Postal code:
Phone:
Fax:
Email address:
Confirm email address:
Website address:
Alternative contact to be reached if you are not available:
Name:
Phone:
Email:
Background Information
1. In what type of organization is your program based? (Please check all that apply.)
   Hospital
   Nursing home
   Health department
   Insurance plan
   Health plan or HMO
   Home health agency
   Community health center
   Private medical practice
   Pharmacy
   Other. Please specify:  
   
2. If your organization is a hospital or nursing home, how many beds are in it?
 
   
3. Approximately how many healthcare workers are candidates for influenza vaccination in your program?
  1 - 50
  51 - 200
  201 - 500
  501 - 1,000
  More than 1,000
Your successful Influenza Vaccination Program
4.

Please summarize the program and provide any significant details.
 
5.

How effective was the program? For example, please provide the number of healthcare workers vaccinated as well as the number targeted during the 2007-08 influenza season and compare with the 2006-07 rates, if known.
 
6.

What was your role within the program you are reporting?
 
7.

When did you begin this program?
 
8.

Who was involved in leading the planning and implementation of the program?
 
9.

How did you promote healthcare worker cooperation with the program?
 
10. Did you use a declination form for staff to decline influenza vaccination?
  Yes
  No
  Not sure
  If yes, was the use of the form mandatory?
  Yes
  No
  Not sure
11.

What types of setting did you use to administer vaccine (e.g., nurses stations, employee health, emergency department, rolling cart, drive-through)?
 
12.

How did you cover the costs of the program?
 
13.

What problems did you encounter and how did you solve them?
 
14.

Were there any unexpected benefits of the program?
 
15.

Based on your experiences with the program, will you be making any changes for next season?
 
16.

Please provide any additional comments you may have.
 
   There may be a delay after sending.  
Please be patient.
 
You will receive an email message containing a copy of the information entered here.
 
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American Medical Association: Science, Research, and Technology
Litjen (L.J.) Tan, PhD litjen.tan@ama-assn.org
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