Goal-setting - National Adult and Influenza Immunization ...



Post-Acute and Long-Term Care Facility Healthcare Professional VaccinationGoal-Setting and Policy Decision-Making WorksheetUse this worksheet to set goals and make decisions about your vaccination program. Goal-setting Vaccination rates will be tracked for: (select one)Nursing staff onlyAll staff (including housekeeping, dietary, administration, etc.)Vaccination rate goals____% after vaccination kick-off event (if one is held, it is usually in mid-October)____% by October 31____% by December 10____% for the influenza season overall (including anyone working in facility October – March)Policy implementationStaff vaccination policyAnnual influenza vaccination offered free to all staff at work and: (select one)Strongly encouraged by managementRequired unless a declination form is signedRequired as a condition of employment Accepted reasons for declining vaccination (select all that apply)Personal reasons Religious objectionMedical contraindicationConsequences of declining vaccination (select all that apply)NoneCompletion of an educational moduleMasking: (select one) During outbreaks in the facility During outbreaks in the communityThroughout the influenza seasonRemoval from schedule: (select one)During outbreaks in the facilityDuring outbreaks in the communityThroughout the influenza seasonTerminationEducation and training on influenza and pneumoniaIn-service sessions for existing staff (select all that apply)Offered annually before the flu seasonOffered monthly throughout the yearIn-service attendance (select all that apply)Encouraged annuallyRequired attendance annuallyRequired for all new hires during the flu seasonVaccination provided at in-services during flu season (select one)YesNoDocumentationVaccination tracking sheets will document:Staff vaccination on-siteStaff vaccination elsewhereDeclination of vaccinationHiring and termination during flu seasonProof of vaccination for staff vaccinated elsewhere (select one)RequiredNot requiredRecords maintained (select all that apply)On vaccination status tracking sheetIn individual employee health recordsIn employee HR recordsVaccination during hiring and staff orientation during flu season (October – March)Strategies (select all that apply)Inquire about vaccination status during interviewsState policy upon hire and during orientationOffer vaccination during hiring and orientation Other: _____________________________________________________________________Vaccination opportunities (select all that apply)During Mantoux testingOrientation (if no Mantoux test required)Other:_____________________________________________________________________Vaccination for on-call staff and those returning from leave (select all that apply)Communicate with staff via letters home, phone calls, and/or emailsEncourage participation in kick-off eventInvite staff to receive vaccination on-site Require proof of off-site vaccination Communication with staffStrategies for communicating goals and policies with staff (select all that apply)Posters in break rooms or: _____________________________________________________Announcements during meetingsFlyers or letters distributed at workMailings sent home to staffVaccination gauge (for goals and progress)Other:______________________________________________________________________Assigning rolesWho will take responsibility for ensuring that the following tasks are completed?Overseeing policy implementation: ________________________________________________________Tracking staff vaccination status: __________________________________________________________Ensuring vaccination of on-call and on-leave staff: ____________________________________________Selecting in-service materials: ____________________________________________________________Leading in-service sessions: ______________________________________________________________Organizing the kick-off event: ____________________________________________________________Vaccinating staff: ______________________________________________________________________Displaying educational posters: ___________________________________________________________Developing and distributing educational materials for distribution to staff: ________________________ Updating the vaccination gauge: __________________________________________________________ ................
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