Get the free 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM - cdph ca
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This document is used by California General Acute Care Hospitals to report influenza vaccination data for their employees and non-employee healthcare personnel for the 2011-2012 influenza season.
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How to fill out 2011-2012 influenza vaccinationdeclination surveillance
How to fill out 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM
01
Obtain the 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM from the appropriate health authority or medical provider.
02
Fill in your personal information, including your name, date of birth, and contact information.
03
Indicate your vaccination status by checking the appropriate box for vaccination or declination.
04
If vaccinated, provide details such as the date of vaccination and the type of vaccine received.
05
If declinating, you may need to provide a reason for declining the vaccination. Include relevant information as required.
06
Review the form for accuracy and completeness.
07
Sign and date the form at the bottom.
08
Submit the completed form to the designated authority or keep it for your records.
Who needs 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
01
Individuals who are required to document their influenza vaccination status for public health compliance, especially in healthcare settings.
02
Employees in sectors mandated to receive seasonal influenza vaccine due to exposure risk.
03
Students in academic settings where vaccination is a requirement.
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What is 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
The 2011-2012 Influenza Vaccination/Declination Surveillance Form is a document used to track the vaccination status of individuals regarding the influenza vaccine for the 2011-2012 flu season.
Who is required to file 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
Individuals who are part of healthcare settings or other designated groups where influenza vaccination is recommended or required must file the form.
How to fill out 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
To fill out the form, individuals must provide personal information, indicate their vaccination status, and if declining the vaccine, they should state their reason for declination.
What is the purpose of 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
The purpose of the form is to gather data on vaccination rates and reasons for declination which helps in public health planning and monitoring vaccination efforts.
What information must be reported on 2011-2012 INFLUENZA VACCINATION/DECLINATION SURVEILLANCE FORM?
The reported information includes personal identification details, vaccination status, reasons for declining the vaccine, and any adverse reactions experienced.
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