Vaccination Log/Data Collection Sheet



Vaccination Tally Sheet

Instructions

This tool allows for separate tallying of resident and staff vaccination data. Specify below the time period for which data is being summarized. Because resident census fluctuates, choose a method for determining census that you will be able to use consistently. Examples include the midpoint census, the average census, or the highest census during the chosen data collection time period. Examples of contraindications: allergic to eggs, hospice patient, medical contraindications.

Time Period: ___________ to ___________ Facility: ___________________

Floor/Wing: ________________ Recorder: _________________

Residents

|Total Resident census | |

|Total Residents receiving flu vaccine | |

|Total Residents for whom flu vaccine contraindicated and/or resident refused | |

|Total Residents receiving pneumonia vaccine in facility | |

|Total Residents previously vaccinated for pneumonia | |

|Total Residents for whom pneumonia vaccine contraindicated and/or resident refused | |

| | |

|Staff | |

|Total number of Staff | |

|Total Staff receiving flu vaccine in facility | |

|Total Staff receiving flu vaccine outside of facility | |

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The Vaccination Tally Sheet can be used to tally the numbers of residents and staff who have received each of the two vaccines, the numbers for whom the vaccines were contraindicated, and the numbers who refused. This Tally Sheet can be completed on a monthly basis, at the end of flu season, or for any time period desired.

Sample Vaccination Tally Sheet

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