Docstoc

NQF_measure_spreadsheet_0830

Document Sample
NQF_measure_spreadsheet_0830 Powered By Docstoc
					               Healthcare Personnel (HCP) Influenza Vaccination Data Collection Tool

Contact Information
Name of Person Submitting Form:
Department of Data Collection:
Healthcare Site Name:
Healthcare Site Address:


Healthcare Site Type:
Today's Date (mm/dd/yyyy):
Phone Number of Person Submitting Form:
Email address of Person Submitting Form:

                                                                                        Non-employees,         Non-employees,
Total number of persons who…                                     Employees a             Credentialed b            Otherc

                                                                                   Does not necessarily equal sum of numerator compone
Denominator Information                                                            (n=4)

     Have worked [at any point]
     at this healthcare care site
     between October 1, 2010
     and March 31, 2010                                                                Does not include persons with unknown vaccination
                                                                                       # unknowns = {# HCP in denominator} - {# HCP in
                                                                                       numerator}
Numerator Information

     Received an influenza vaccine
     at this healthcare site
     Received influenza
     vaccine elsewhere
     Have a medical contraindication
     for the influenza vaccine

     Declined to receive the
     influenza vaccine for
     non-medical reasons
     Comments:




 a
     All employees who receive a paycheck, including those with and without clinical responsibilities (e.g., nursing, clerical staff, etc.).
 b   Includes personnel who do not receive a paycheck and are not credentialed medical staff (e.g., students, volunteers, etc.)
 c   Includes licensed practitioners and physicians who do not receive a paycheck [from this facility] (e.g., physicians, nurse practitioners,
     physician assistants, midwives, etc.)
                         Healthcare Personnel (HCP) Influenza Vaccination Data Collection Tool
Contact Information

Name of Person Submitting Form:
Department of Data Collection:
Healthcare Institution Name:
Healthcare Institution Address:


Healthcare Institution Type:
Today's Date (mm/dd/yyyy):
Phone Number of Person Submitting Form:
Email Address of Person Submitting Form:

                                                                                                Non-employees,                  Non-employees,
Total number of persons who…                                     Employees a                     Credentialed b                    Otherc

     Denominator Information
      Have worked at this health-
      care institution between October 1,
      2010 and March 31, 2010
     Numerator Information

      Received an influenza vaccine
      at this healthcare institution
      Received an influenza
      vaccine elsewhere
      Have a medical contraindication
      for the influenza vaccine

      Declined to receive the
      influenza vaccine for
      non-medical reasons
     Comments:




 a
     All employees who receive a paycheck from this healthcare institution or its affiliates, including those with and without clinical responsibilities
 b   Includes licensed practitioners and physicians who do not receive a paycheck [from this institution or its affiliates].
 c   Includes all other personnel who do not receive a paycheck and are not credentialed medical staff (e.g., contract staff, students, volunteers, etc.)
enza Vaccination Data Collection Tool




                                                       Non-employees,
                                                          Otherc




on or its affiliates, including those with and without clinical responsibilities.

not credentialed medical staff (e.g., contract staff, students, volunteers, etc.)

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:12/8/2013
language:Unknown
pages:3