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OMB No. 0920-0666 Exp. Date: 03-31-2011 High Risk Inpatient Influenza Vaccination Method B Form - Part 1 * required for saving Facility ID: Event #: *Patient ID: Secondary ID: Patient Name, Last: *Gender: F M Social Security #: First: Middle: *Date of Birth: Ethnicity (specify): Race (specify): *Event Type: FLUVX Vaccination type: Influenza *Influenza subtype: † Seasonal † Non-seasonal *Date Admitted to Facility: *High Risk Criteria for Seasonal Influenza (Check all that apply.) † Person aged ≥ 50 years † Person aged 6 months – 18 years † Person aged 6 months – 18 years receiving long-term aspirin therapy † Resident of nursing home or other chronic-care facility † Person who lives with or cares for children younger than 6 months of age † Pregnancy † Person over 6 months of age who has chronic health disorder(s) or compromised immune system (see below for high risk conditions) *High Risk Criteria for Non-seasonal Influenza (Check all that apply.) † Person aged 6 months - 24 years † Person who lives with or cares for children younger than 6 months of age † Pregnancy † Healthcare or emergency medical services worker † Person aged 25 through 64 who has chronic health disorder(s) or compromised immune system (see below for high risk conditions) *Vaccine Offered: † Yes † No (If Yes complete HRIIV Method B Form – Part 2, CDC 57.133) High Risk Conditions • Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus) • Any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration • Immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]) See NHSN Manual for further information on high risk disease conditions. Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.132 rev 1, NHSN v6.0