Pt Flu Season Log by bcs24005

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									Agency:                                                                                                                                     Patient Influenza/Pneumococcal Immunization Log
Branch:                                                                                                                                                       October - March
Year:

                                                                                                                      Refusal Reason Codes: 1 - Personal preference      2 - Religious/Culture beliefs   3 - Other
                                                                                                   ASSESS                                                                      ACCESS                                           ADMINISTERed

                                                                        Patient Assessment                             Vaccine refused by                Vaccine administered by agency or referred to community
                                                                                              Eligible for Vaccines                                                                                                          Patient's Current Status
                                                                               Status                                        patient                                (e.g physician office, local clinics)                                                    D/C from
                                                                                                                                                                                                                                                              agency
                                                                          FLU       PPV         FLU         PPV          FLU       PPV                         FLU                                        PPV                  FLU              PPV

                                                                                                                       Reason    Reason
                                                                                                                                                         Referred to                    Admin by                Admin in
  Medical                            First        SOC        Team                                                       (1-3)     (1-3)     Admin by                     Admin in                 Referred to
                  Last Name                                             (Y or N)   (Y or N)   (Y or N)    (Y or N)                                       Community                       Agency                Community   (Y, N, or N/A)   (Y, N, or N/A)     (Y)      Comments
  Record #                          Initial       Date     (Optional)                                                                       Agency (Y)                 Community (Y)             Community (Y)
                                                                                                                                                             (Y)                           (Y)                    (Y)




             * PPV - pneumoccocal polysaccharide vaccine                                                                                                                                                                                                                  Page 1 of 9
                                                                                                 ASSESS                                                                     ACCESS                                          ADMINISTERed

                                                                      Patient Assessment                            Vaccine refused by                Vaccine administered by agency or referred to community
                                                                                            Eligible for Vaccines                                                                                                        Patient's Current Status
                                                                             Status                                       patient                                (e.g physician office, local clinics)                                                   D/C from
                                                                                                                                                                                                                                                          agency
                                                                        FLU       PPV         FLU         PPV        FLU        PPV                         FLU                                     PPV                    FLU              PPV

                                                                                                                    Reason    Reason
                                                                                                                                                      Referred to                   Admin by                Admin in
Medical                            First        SOC        Team                                                      (1-3)     (1-3)     Admin by                     Admin in                Referred to
                Last Name                                             (Y or N)   (Y or N)   (Y or N)    (Y or N)                                      Community                      Agency                Community   (Y, N, or N/A)   (Y, N, or N/A)     (Y)      Comments
Record #                          Initial       Date     (Optional)                                                                      Agency (Y)                 Community (Y)            Community (Y)
                                                                                                                                                          (Y)                          (Y)                    (Y)




           * PPV - pneumoccocal polysaccharide vaccine                                                                                                                                                                                                                Page 2 of 9
Agency:                                                                                                                              Staff Influenza Immunization Log
Branch:                                                                                                                                        October - March
Year:

                                                                                                          Refusal Reason Codes:1 - Personal preference     2 - Religious/Culture beliefs   3 - Other
                                                                                             ASSESS                                                               ACCESS                                     ADMINISTERed

                                                                     Staff Assessment                           Vaccine refused by         Vaccine administered by agency or referred to community
                                                                                        Eligible for Vaccines                                                                                               Staff's Current Status
                                                                           Status                                     staff                           (e.g. physician office, local clinics)

                                                                           FLU                  FLU                    FLU                                           FLU                                            FLU


                                                          Team                                                       Reason                                    Referred to
Employee #      Last Name               First Name                       (Y or N)             (Y or N)                               Admin by Agency (Y)                           Admin in Community (Y)       (Y, N, or N/A)       Comments
                                                        (Optional)                                                    (1-3)                                   Community (Y)




          * PPV - pneumococcal polysaccharide vaccine                                                                                                                                                                                Page 3 of 9
                                                                                            ASSESS                                                              ACCESS                                    ADMINISTERed

                                                                    Staff Assessment                           Vaccine refused by         Vaccine administered by agency or referred to community
                                                                                       Eligible for Vaccines                                                                                             Staff's Current Status
                                                                          Status                                     staff                           (e.g. physician office, local clinics)

                                                                          FLU                  FLU                    FLU                                          FLU                                           FLU


                                                         Team                                                       Reason                                    Referred to
Employee #     Last Name               First Name                       (Y or N)             (Y or N)                               Admin by Agency (Y)                         Admin in Community (Y)       (Y, N, or N/A)       Comments
                                                       (Optional)                                                    (1-3)                                   Community (Y)




         * PPV - pneumococcal polysaccharide vaccine                                                                                                                                                                              Page 4 of 9
                                                                                            ASSESS                                                              ACCESS                                    ADMINISTERed

                                                                    Staff Assessment                           Vaccine refused by         Vaccine administered by agency or referred to community
                                                                                       Eligible for Vaccines                                                                                             Staff's Current Status
                                                                          Status                                     staff                           (e.g. physician office, local clinics)

                                                                          FLU                  FLU                    FLU                                          FLU                                           FLU


                                                         Team                                                       Reason                                    Referred to
Employee #     Last Name               First Name                       (Y or N)             (Y or N)                               Admin by Agency (Y)                         Admin in Community (Y)       (Y, N, or N/A)       Comments
                                                       (Optional)                                                    (1-3)                                   Community (Y)




         * PPV - pneumococcal polysaccharide vaccine                                                                                                                                                                              Page 5 of 9
Agency:                                                                                                                                   Patient Pneumococcal Immunization Log
Branch:                                                                                                                                              April - September
Year:

                                                                                                               Refusal Reason Codes: 1 - Personal preference    2 - Religious/Culture beliefs   3 - Other
                                                                                                  ASSESS                                                               ACCESS                                    ADMINISTERed

                                                                        Patient Assessment                           Vaccine refused by          Vaccine administered by agency or referred to community
                                                                                             Eligible for Vaccines                                                                                             Patient's Current Status
                                                                               Status                                      patient                          (e.g physician office, local clinics)                                         D/C from
                                                                                                                                                                                                                                           agency
                                                                               PPV                   PPV                    PPV                                           PPV                                           PPV


  Medical                             First        SOC       Team                                                         Reason                                Referred to Community
                  Last Name                                                  (Y or N)              (Y or N)                               Admin by Agency (Y)                         Admin in Community (Y)        (Y, N, or N/A)          (Y)      Comments
  Record #                           Initial       Date    (Optional)                                                      (1-3)                                          (Y)




             * PPV - pneumoccocal polysaccharide vaccine                                                                                                                                                                                              Page 6 of 9
                                                                                                ASSESS                                                               ACCESS                                    ADMINISTERed

                                                                      Patient Assessment                           Vaccine refused by          Vaccine administered by agency or referred to community
                                                                                           Eligible for Vaccines                                                                                             Patient's Current Status
                                                                             Status                                      patient                          (e.g physician office, local clinics)                                         D/C from
                                                                                                                                                                                                                                         agency
                                                                             PPV                   PPV                    PPV                                           PPV                                           PPV


Medical                             First        SOC       Team                                                         Reason                                Referred to Community
                Last Name                                                  (Y or N)              (Y or N)                               Admin by Agency (Y)                         Admin in Community (Y)        (Y, N, or N/A)          (Y)      Comments
Record #                           Initial       Date    (Optional)                                                      (1-3)                                          (Y)




           * PPV - pneumoccocal polysaccharide vaccine                                                                                                                                                                                              Page 7 of 9
                                                                                                ASSESS                                                               ACCESS                                    ADMINISTERed

                                                                      Patient Assessment                           Vaccine refused by          Vaccine administered by agency or referred to community
                                                                                           Eligible for Vaccines                                                                                             Patient's Current Status
                                                                             Status                                      patient                          (e.g physician office, local clinics)                                         D/C from
                                                                                                                                                                                                                                         agency
                                                                             PPV                   PPV                    PPV                                           PPV                                           PPV


Medical                             First        SOC       Team                                                         Reason                                Referred to Community
                Last Name                                                  (Y or N)              (Y or N)                               Admin by Agency (Y)                         Admin in Community (Y)        (Y, N, or N/A)          (Y)      Comments
Record #                           Initial       Date    (Optional)                                                      (1-3)                                          (Y)




           * PPV - pneumoccocal polysaccharide vaccine                                                                                                                                                                                              Page 8 of 9
Agency:
Branch:
Year:

Immunization Summary Report
Our agency’s immunization program supports improving patient immunizations for both influenza and pneumonia.


Flu Season (October - March)
Total patients assessed during flu season out of all patients entered in log:               N/A

ASSESS                                                                                      FLU                PPV
  Patients that were already immunized:                                                     N/A                N/A
  Patients not immunized who are eligible for immunization:                                 N/A                N/A
  Patients eligible for immunization who refused immunization:                              N/A                N/A
ACCESS                                                                                      FLU                PPV
  Immunizations administered by our agency to eligible patients:                            N/A                N/A
  Immunizations referred to community:                                                      N/A                N/A
  Immunizations administered in community:                                                  N/A                N/A
ADMINISTERed                                                                                FLU                PPV
  Current patient immunization status out of all eligible patients:                         N/A                N/A

Staff Immunization
Total staff assessed during flu season out of all staff entered in log:                     N/A

ASSESS                                                                                      FLU
  Staff that were already immunized:                                                        N/A
  Staff not immunized who are eligible for immunization:                                    N/A
  Staff eligible for immunization who refused immunization:                                 N/A
ACCESS                                                                                      FLU
  Immunizations administered by our agency to eligible staff:                               N/A
  Immunizations referred to community:                                                      N/A
  Immunizations administered in community:                                                  N/A
ADMINISTERed                                                                                FLU
  Current staff immunization status out of all eligible staff:                              N/A

Non-Flu Season (October - March)
Total patients assessed during non-flu season out of all patients entered in log:           N/A

ASSESS                                                                                      PPV
  Patients that were already immunized:                                                     N/A
  Patients not immunized who are eligible for immunization:                                 N/A
  Patients eligible for immunization who refused immunization:                              N/A
ACCESS                                                                                      PPV
  Immunizations administered by our agency to eligible patients:                            N/A
  Immunizations referred to community:                                                      N/A
  Immunizations administered in community:                                                  N/A
ADMINISTERed                                                                                PPV
  Current patient immunization status out of all eligbile patients:                         N/A

								
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