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HCP Influenza Vaccination Summary Reporting FAQs
Updated September 20, 2024
Reporting Requirements: General
Q1. Which facilities and units are required to report healthcare personnel (HCP) influenza vaccination summary data through NHSN for the 2024-2025 influenza season?
CMS-certified free-standing acute care facilities, inpatient rehabilitation facilities (IRFs), critical access hospitals, long-term acute care facilities, prospective payment system (PPS)-exempt cancer hospitals, and skilled nursing facilities (SNFs) are required to report HCP influenza vaccination summary data through NHSN.
IRF units located within acute care facilities, long-term acute care facilities, critical access hospitals, and inpatient psychiatric facilities are also required to report HCP influenza vaccination data through NHSN.
Q2. Can my facility still submit HCP influenza vaccination summary data through NHSN even if we are not required to do so by CMS?
Ambulatory surgery centers, free-standing inpatient psychiatric facilities (IPFs) and outpatient dialysis facilities are no longer required to report HCP influenza vaccination summary data through NHSN beginning with the 2018-2019 influenza season. In August 2018, the Centers for Medicare and Medicaid Services (CMS) eliminated the HCP Influenza Vaccination Summary Measure from its quality reporting program for IPFs. This change applies to both free-standing IPFs and IPF units that are located within acute care facilities, long-term acute care facilities, critical access hospitals, and inpatient rehabilitation facilities.
However, please note that reporting these data may be required for certain facilities based on state or other reporting requirements. Facilities not required by CMS to submit data are welcome to voluntarily report HCP influenza vaccination summary data through NHSN. If these data are entered into NHSN by June 30, the data will be included in the regional-level data reports produced by NHSN for that influenza season (July 1 through June 30).
Q3. Where can I find information on the CMS final rule for IRFs and IRF units on reporting HCP influenza vaccination summary data?
View CMS final rule for IRFs [PDF – 1 MB] (47905-47906).
Q4. Where can I find the operational guidance for IRFs to report HCP influenza vaccination summary data to fulfill CMS’s IRF Quality Reporting Program requirements?
Q5. Where can I find information on the CMS final rule for long-term acute care facilities (LTACs) on reporting HCP influenza vaccination summary data?
View final rule [PDF – 1 MB] (50857-50858).
Q6. Where can I find the operational guidance for LTACs to report HCP influenza vaccination summary data to fulfill CMS’s Long-Term Care Hospital Quality Reporting (LTCHQR) requirements?
Q7. Where can I find information on the CMS final rule for skilled nursing facilities (SNFs) on reporting HCP influenza vaccination summary data?
View final rule on the federal register website.
Q8. Where can I find the operational guidance for SNFs to report HCP influenza vaccination summary data to fulfill CMS’s SNF Quality Reporting Program (QRP) requirements?
Operational Guidance is found in the document, Operational Guidance for Skilled Nursing Facilities to Report Annual Influenza Vaccination Data [PDF – 178KB].
Q9. Who should I contact if I have questions on the SNF QRP requirements?
For questions related to SNF QRP requirements, please contact CMS at SNFQualityQuestions@cms.hhs.gov.
Q10. I am reporting HCP influenza vaccination summary data for a LTAC facility with an IRF unit. Will I need to report IRF unit data separately in NHSN?
Yes. CMS published a final rule effective on October 1, 2019 extending reporting requirements for HCP influenza vaccination summary data to IRF units located outside of acute care and critical access hospitals. This applies to IRF units located within LTACs or inpatient psychiatric facilities (IPFs). Beginning with the 2020-2021 influenza season, IRF units located within LTACHs and IPFs must submit data for the entire influenza vaccination season (October 1 through March 31) to NHSN.
Q11. I am reporting HCP influenza vaccination summary data for a LTAC facility with an IRF unit. How should I report the IRF unit data in NHSN?
Influenza vaccination summary data for HCP working in this IRF unit should be reported separately from the LTAC facility summary data. On the influenza vaccination summary data entry screen, use the dropdown box under the location field to select “IRF Unit(s)” before entering data. HCP working in the IRF unit should not be counted in the summary report for the rest of the LTAC facility unless they also work in other areas of the LTAC facility between October 1 and March 31.
Q12. I report data to NHSN for my free-standing IPF. Should I submit HCP influenza vaccination summary data?
You are not required to report HCP influenza vaccination summary data for the free-standing IPF. However, you should report these data for any CMS-certified IRF units located within the IPF.
Q13. Where can I find a recorded training presentation covering new reporting requirements for inpatient rehabilitation facility units located within long-term acute care facilities and inpatient psychiatric facilities?
Please view the presentation for Influenza Vaccination Summary Reporting for IRF Units in LTACHs and IPFs
Q14. I need to report HCP influenza vaccination summary data for an IRF unit. How do I add an IRF unit as a location to my existing facility in NHSN?
Please use the following resource to add an IRF unit as a location in your facility. [PDF – 504 KB]
Q15. Which HCP groups are required to be included in HCP influenza vaccination summary reports to CMS?
CMS requires reporting on influenza vaccination for three categories of HCP: employees, licensed independent practitioners (non-employee physicians, advanced practice nurses, and physician assistants), and adult students/trainees and volunteers aged 18 and over. In other words, there is one category for all employees and two separate categories for non-employees. Categories are mutually exclusive. NHSN includes an option to enter vaccination data for other contract personnel and vendors, but these data are not currently required by CMS. Facilities wishing to track influenza vaccination rates among other contract personnel and vendors can choose to use this optional reporting capacity.
Q16. Which data collection forms are facilities or units required to complete for reporting HCP influenza vaccination summary data to NHSN?
To report HCP influenza vaccination summary data, all facilities or units must complete the HCP Influenza Vaccination Summary Form.
In addition to this form, dialysis centers that do not provide in-center hemodialysis are required to complete a third form before they can enter HCP influenza vaccination summary data. This form is called the Home Dialysis Center Practices Survey. The survey captures information about various topics such as surveillance practices, vaccination, and vascular access.
The Seasonal Survey on Influenza Vaccination Programs for HCP is not required at this time. However, facilities are encouraged to complete this short survey as the information can help CDC examine the relationship of different vaccination program elements to facility-reported vaccination percentages.
Q17. Are the data reporting timeframes the same for the denominator and numerator of the HCP influenza vaccination measure?
The timeframes for the denominator and numerator of the HCP influenza vaccination measure are different. The denominator includes HCP who are physically present in the healthcare facility for at least 1 working day from October 1 through March 31 (the reporting period). The numerator timeframe begins “as soon as vaccine is available.” Therefore, vaccinations given any time during the influenza season from the time that season’s vaccine is available at a facility through March 31 should be reported in the numerator. For example, if a healthcare worker was vaccinated in September, but then ceased to work at the facility before October 1, they would not be counted in the numerator or denominator data for that season. However, if a healthcare worker was vaccinated in September and continued to work at the facility for at least one day from October 1 through March 31, they would be counted in both the numerator and denominator. The reason the numerator and denominator cover different timeframes is to account for potential delays in vaccine availability.
Q18. How can I report annual healthcare personnel influenza vaccination summary data?
Data can be reported in two ways:
1. Entering data directly into the NHSN application through the Healthcare Personnel Influenza Vaccination Module.
2. Uploading .CSV files into the Healthcare Personnel Influenza Vaccination Module. Instructions for uploading data, a .CSV file template, and .CSV example file can be accessed through the following webpage: HCP Flu Vaccination | HPS | NHSN | CDC.
Q19. What is the monthly reporting plan in NHSN and how is it used for HCP influenza vaccination reporting?
The monthly reporting plan indicates to the NHSN system which modules and protocols a user intends to follow for surveillance purposes. As of the 2022-2023 influenza season, the monthly reporting plan is no longer required to complete prior to entering annual healthcare personnel influenza vaccination data beginning with the 2022-2023 influenza season. Instead, upon saving or uploading data, users will agree to the following: 1) The data reported are consistent with definitions outlined in NHSN surveillance protocols (including tables of instructions and frequently asked questions) and 2) The data will be sent to the Centers for Medicare and Medicaid Services (CMS) to fulfill CMS quality reporting requirements (when applicable).
Q20. Do I need to report HCP influenza vaccination summary data each month?
Monthly reporting in NHSN is not required; entering a single influenza vaccination summary report at the end of the reporting period for the influenza season will meet the minimum data requirements for NHSN participation. However, facilities are encouraged to update HCP influenza vaccination summary counts on a monthly basis so the data can be used to inform influenza vaccination activities at the facility.
Q21. How long are facilities or units able to edit HCP influenza vaccination summary data in NHSN?
Each facility or unit’s HCP influenza vaccination summary data report must be entered into NHSN by May 15 for data to be shared with CMS. Facilities and units can edit data any time after May 15, but these changes will not be sent to CMS. In addition, the influenza season is defined by NHSN as July 1 to June 30, so changes after June 30 of an influenza season may not be used in state or regional reports created by CDC for that influenza season.
Q22. When is the deadline for submitting HCP influenza vaccination summary data to CMS?
The reporting period for the 2024-2025 influenza season is from October 1, 2024 through March 31, 2025. To meet CMS reporting requirements, HCP influenza vaccination summary data reports must be entered into NHSN no later than May 15, 2025 for the 2024-2025 influenza season. Facilities can edit their data after May 15, but the revised data will not be shared with CMS.
Q23. I entered my HCP influenza vaccination summary data into NHSN. How can I confirm that my data were entered correctly and will be shared with CMS?
One way to confirm data entry is to login to the Healthcare Personnel Safety Component and then choose your facility. Next, go to Vaccination Summary on the left-hand navigation bar, click on Annual Vaccination Flu Summary, then Find. For Summary Data Type, choose the Influenza Vaccination Summary, and in the Flu Season drop-down box, choose the influenza season you would like to verify. Facilities should also confirm that the correct CCN is entered into NHSN. Facilities can also run a report that will show when data were first entered and last modified in the NHSN application. For instructions on running this report, please see: Create dates for influenza QRG (cdc.gov).
Facilities can also review step-by-step instructions on how to confirm their data submission [PDF – 300 KB].
Q24. What should a facility do if the NHSN Facility Administrator has left?
When the NHSN Facility Administrator role needs to be reassigned, the current NHSN Facility Administrator must complete the following form: Change NHSN Facility Administrator | NHSN | CDC.
Reporting Requirements: Acute Care Facility
Q1. Where can I find the operational guidance for acute care hospitals to report HCP influenza vaccination summary data to fulfill CMS’s IQR Program requirements?
Q2. Where can I find information on the HCP influenza vaccination summary reporting requirements for critical access hospitals (CAHs)?
View HCP influenza vaccination summary reporting requirements for CAHs [PDF – 100 KB].
Q3. Are the reporting requirements for CAHs the same as acute care hospital requirements?
Yes, CAHs should follow the same reporting requirements that apply to acute care hospitals reporting HCP influenza vaccination summary data to NHSN.
Q4. Are CAHs required to submit separate vaccination reports for HCP working in outpatient units and inpatient units?
No. Like acute care hospitals, CAHs should submit a single report on the vaccination status of HCP working in inpatient and outpatient departments of the facility that share the same CCN.
Q5. Should acute care facilities separate HCP working in the outpatient areas from those working in inpatient areas when reporting HCP influenza vaccination summary data?
CMS published a final rule in November 2018 eliminating the requirement for hospital outpatient departments to report HCP influenza vaccination summary data through NHSN beginning with the 2018-2019 influenza season. On February 7, 2019, CMS and CDC issued guidance to clarify that this measure does not separate out HCP who only work in the inpatient or outpatient areas, or work in both:
“The IQR program Healthcare Personnel Influenza Vaccination measure is a facility-wide measure and does not separate out employees who only work in the inpatient or outpatient areas or work in both. Due to the burden of trying to separate out the counts for inpatient and outpatient, CMS allows facilities to collect and submit a single vaccination count to include all hospital-wide employees who meet the criteria, regardless of whether they work inpatient or outpatient. The hospital-wide or combined counts should be entered on one single influenza vaccination summary data form in NHSN. This includes all units/departments, inpatient and outpatient, that share the same CMS Certification Number (CCN) as the hospital and are affiliated with the acute care facility.”
The CMS Final Rule can be accessed in the document, US Department of Health and Human Services. Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.
Q6. How should acute care facilities report HCP influenza vaccination summary data?
Facilities should follow the guidance below when making determinations about which areas of the acute care facility to include when reporting HCP influenza vaccination summary data to NHSN as part of the CMS Hospital Inpatient Quality Reporting (IQR) Program:
- Include all inpatient units/departments of the acute care facility sharing the exact same CMS Certification Number [CCN] (100% identical) as the acute care facility, regardless of distance from the facility.
- Include all outpatient units/departments of the acute care facility sharing the exact same CCN (100% identical) as the acute care facility, regardless of distance from the facility.
- Exclude all inpatient and outpatient units/departments of the acute care facility with a different CCN (even if different by only one letter or number) from the acute care facility.
Q7. Why are free-standing IPFs required to enroll in NHSN, while IPF units having different CMS certification numbers (CCNs) from the acute care or critical access facilities usually do not need to do so?
IPF units do not need to enroll or activate the Healthcare Personnel Safety (HPS) Component unless their affiliated acute care or critical access facility is not already enrolled in NHSN or the IPF unit is not physically located within the walls of the affiliated acute care or critical access facility. IPF units located within hospitals can simply be mapped as locations of the already-enrolled acute care or critical access facility. Once the IPF unit is added as a location of the facility, the IPF unit-specific CCN is linked with that location. View more information about how to map an IPF unit and add an IPF unit-specific CCN [PDF – 200 KB].
Q8. I am reporting HCP influenza vaccination summary data for an IRF unit that is physically located within our acute care facility. The IRF unit has the same CMS Certification Number (CCN) as the hospital except for an “R” (or “T”) in the third position. How should I report the IRF unit data in NHSN?
Influenza vaccination summary data for HCP working in this IRF unit should be reported separately from the acute care hospital summary data. On the influenza vaccination summary data entry screen, use the dropdown box under the location field to select “IRF Unit(s)” before entering data. HCP working in the IRF unit should not be counted in the summary report for the rest of the acute care facility unless they also work in other inpatient or outpatient units of the acute care facility between October 1 and March 31.
Q9. Why are free-standing IRFs required to enroll in NHSN, while IRF units having different CCNs from their acute care or critical access facilities usually do not need to do so?
IRF units do not need to enroll or activate the HPS Component unless their affiliated acute care or critical access facility is not already enrolled in NHSN or the IRF unit is not physically located within the walls of the affiliated acute care or critical access facility. IRF units located within hospitals can simply be mapped as locations of the already-enrolled acute care or critical access facility. Once the IRF unit is added as a location of the facility, the IRF unit-specific CCN is linked with the facility so IRF unit data can be sent to CMS appropriately. View more information about CMS certified IRF Locations [PDF – 504 KB].
Q10. If my IRF unit has the exact same CCN as my acute care or critical access facility, do I need to report the IRF unit data separately from this facility?
No. If the IRF unit CCN is 100% identical to the CCN of its acute care or critical access facility, then separate HCP influenza vaccination summary data reporting is not required by CMS. Therefore, counts of HCP working in the IRF unit can be included in the total counts for the acute care or critical access facility. However, IRF units whose CCNs differ from the acute care or critical access facility CCN by even one letter or number – for example, having a “T” or “R” in the third position – must either be mapped as locations of the parent facility or enrolled as a separate NHSN facility, and their data must be reported separately.
Q11. There are multiple IRF units located within my facility. Should I report HCP influenza vaccination summary data separately in NHSN for each individual unit?
No. The HCP influenza vaccination summary data of each individual IRF unit should be combined and submitted to NHSN as a single summary data report combining all CMS IRF units within the facility.
Q12. My health system administers influenza vaccination in an acute care hospital. Some HCP working in an IRF unit of the acute care facility that is part of our health system receives influenza vaccination in the acute care hospital. How should I categorize the vaccination status of these HCP?
Some health systems have a single group responsible for providing influenza vaccination to HCP working at several types of healthcare facilities and units that are a part of the system. If these HCP receive influenza vaccination that is administered under the umbrella of the health system, then they should be documented as “receiving influenza vaccination at the healthcare facility” (#2 on the Healthcare Personnel Influenza Vaccination Summary report form) as part of the total counts for the IRF unit reporting in this facility.
Q13. I used to report data for my CMS inpatient psychiatric facility (IPF) unit that is located within an acute care facility. How should I report data for HCP working in this unit now that the CMS requirements for IPFs have changed?
HCP working only in the IPF unit should not be counted in the acute care facility vaccination summary report. Vaccination status of these HCP does not have to be reported to NHSN for CMS purposes, although reporting may be required by the state or locality where the facility operates. However, HCP working in both the CMS IPF unit and in other units of the acute care facility should be included in the acute care facility vaccination summary report.
Q14. I am reporting from a LTAC that is physically within an acute care facility. How should I report the LTAC data in NHSN?
CMS reporting requirements for long-term acute care hospitals are separate from requirements for short-stay acute care hospitals. Because the long-term acute care unit has its own CCN, it should have already enrolled in NHSN as a separate HOSP-LTAC facility. To fulfill CMS LTCHQR requirements, the LTAC must report HCP influenza vaccination summary data separately through the enrolled NHSN LTAC facility. HCP who work in this unit/facility would not be included in the influenza vaccination summary for the acute care hospital, unless they also work in the short-stay acute care facility.
Data Reporting
Q1. What identity proofing documents are required for the Secure Access Management Services (SAMS) process?
Users submit identity proofing documentation as part of the SAMS process, including a notarized identity verification form and supporting documents (driver’s license, passport, etc.). View more information about the SAMS process.
Q2. What CMS Certification Number (CCN) effective date should I list in NHSN for my facility?
The CCN effective date is the official date in which a facility first received its CCN from CMS. For dialysis facilities, the effective date for your CCN should be the date of the CMS certification survey which resulted in the new CCN. To update the CCN or CCN effective date, use the ‘Facility > Facility Info’ option on the left-hand navigation bar within NHSN. At the top of the Facility Information screen, verify and update (if necessary) the CCN or CCN effective date in the appropriate data entry field(s). If any changes have been made, remember to click the ‘Update’ button at the bottom of screen.
Q3. Which NHSN component should I use to submit annual HCP influenza vaccination summary data for my facility?
Facilities must activate the Healthcare Personnel Safety Component in NHSN to report HCP influenza vaccination summary data. Only the NHSN Facility Administrator (FA) can activate a new component. All facility and unit types should submit HCP influenza vaccination summary data to NHSN using this component. This is true even for facilities that may report data primarily through other components, such as long-term care facilities and outpatient dialysis facilities. Please note that reporting weekly influenza vaccination data through the NHSN Long-term Care Facility (LTCF) Component does not fulfill the CMS annual healthcare personnel influenza vaccination data reporting requirement.
Q4. What must I do to report to NHSN for the HCP Influenza Vaccination Summary Measure?
Facilities and units reporting to NHSN for the HCP Influenza Vaccination Summary Measure must follow the NHSN HPS Flu Vaccine Protocol 2022 [PDF – 300 KB].
Q5. How do long-term care facilities activate the Healthcare Personnel Safety Component to report the annual HCP influenza vaccination summary data?
To report annual healthcare personnel influenza vaccination summary data, the NHSN Facility Administrator (FA) must first activate the Healthcare Personnel Safety (HPS) Component. Detailed instructions on how activate this component are outlined here: Enrollment Level 3 Access and HPS Component Activation [PDF – 150 KB].
Q6. Where can I find training on collecting and reporting HCP influenza vaccination summary data to NHSN?
CDC has conducted training webinars on HCP influenza vaccination summary data reporting for multiple facility types. PowerPoint slides and recordings of the trainings are available on the CDC website.
Q7. Does NHSN require influenza vaccination data to be reported for each individual healthcare worker?
No. Facilities are required to report summary rather than individual-level vaccination data. Therefore, information such as employee-level demographic data is not required.
Q8. I logged into my NHSN facility, but I do not have the option to enter HCP influenza vaccination data on the left-hand navigation bar. How can I enter my data?
This is most likely because your NHSN Facility Administrator has not conferred the proper user rights to you. You should contact your Facility Administrator so they can confer the proper rights for you to view and enter data in the HCP Safety Component. If you need to update your Facility Administrator, please use the Facility Administrator change request form.
Q9. The HCP Influenza Vaccination Summary Form in NHSN defines the influenza season as July 1 to June 30. Does this mean that my facility is required to report on twelve months of data even though we do not administer influenza vaccine for all twelve months of the year?
No. Although influenza may occur at any time of the year, you should report data for the reporting period specified in the NHSN protocol, which is October 1 through March 31 for the denominator, including all vaccinations given during the influenza season in the numerator. The July 1 to June 30 time period is used by NHSN to clearly define the end of one influenza season and the beginning of the next influenza season.
Q10. Can facilities or units review HCP influenza vaccination summary data that are entered into NHSN each month?
No. Each time a user enters updated HCP influenza vaccination summary data for a particular influenza season, all previously entered data for that season will be overwritten and a new modified date will be auto-filled by the system. Each HCP influenza vaccination summary data report entered into NHSN should be cumulative: for example, summary vaccination data entered at the end of November would include data from both October and November. Facilities or units wishing to maintain monthly records should save their own copies of each data entry. Please note that monthly reporting in NHSN is not required for HCP influenza vaccination data; entering a single influenza vaccination summary report covering the entire influenza season will meet the minimum data requirements for NHSN participation.
Q11. How can I modify the HCP influenza vaccination summary data that have been entered in NHSN for my facility or unit?
Go to “Flu Summary” and then “Find” on the left-hand navigation bar to identify data for the influenza season you wish to edit. To edit data, first click “Edit” at the bottom of the HCP influenza vaccination summary data entry screen. Next, you will proceed to enter the updated data. Once this is complete, you must save the updated data by clicking the “Save” button at the bottom of the screen. You should then see a message at the top of your screen confirming that your data have been saved.
Q12. Which time zone is reflected for the date last modified timestamp in the NHSN application?
Since February 2024, timestamps (such as “date created” and “date last modified”) fields in the NHSN application have displayed Coordinated Universal Time (UTC). UTC is the international time standard. UTC serves as a uniform and universal reference to measure time across all time zones. UTC has been implemented as part of ongoing NHSN system upgrades and modernization efforts.
Q13. Is each facility or unit required to calculate vaccination percentages when using the Healthcare Personnel Vaccination module?
No. Facilities or units will only need to enter the number of HCP that fall into each of the numerator and denominator categories. The NHSN system will calculate vaccination coverage percentages for you.
Q14. My facility or unit would like to track influenza vaccination for nurses. Is there a way we can track this group separately in NHSN?
Yes, you can use the Custom Field option in NHSN to create new fields for data that you would like to collect and analyze consistently.
Q15. When using the group function, why am I unable to view HCP influenza vaccination summary data for all influenza seasons?
You may need to change how your user rights are defined in order to view data for all influenza seasons. Please contact your Facility Administrator for more information about your user rights. Group Users can also define which influenza season data are available in NHSN. On the “Define Rights-Healthcare Personnel” page in NHSN (Facility > Define Rights), group users can select which influenza seasons will appear in the Group’s data.
Q16. Who do I contact for questions related to NHSN reporting of HCP influenza vaccination summary data?
If you have any questions, please contact NHSN using the NHSN-ServiceNow portal by logging into SAMS: https://sams.cdc.gov.
HCP Categories: General
Q1. What types of nurses are considered licensed independent practitioners?
All advanced practice nurses should be reported in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.
Q2. What types of HCP are included in the “other contract personnel” category?
A suggested list of other contract personnel who might work in a healthcare facility is located in Appendix A of the NHSN HPS Flu Vaccine Protocol 2022 [PDF – 266 KB].
Q3. Should employees who always work off-site or out-of-state, such as employees practicing telemedicine, be included in our HCP summary vaccination data reports?
No. Only HCP physically working at the healthcare facility for at least 1 day from October 1 through March 31 are included.
Q4. Should I count HCP who are not working with patients, but because of staff meetings, etc. are physically in the facility?
You should count HCP who meet protocol definitions and perform any work duty in the facility for at least 1 day from October 1 through March 31, regardless of clinical responsibility or patient contact. For example, you should count HCP having official responsibilities in the facility such as attending regularly scheduled meetings or required training. However, you would not need to count HCP who are not officially in the facility for work duties (e.g., coming into the facility for lunch) during the reporting period.
Q5. My healthcare system has two facilities, A and B. If an individual works at facility A for 1 day during the influenza season and works at facility B for 15 days during the influenza season, should I count them in the data for both facilities?
Yes, all employees, non-employee licensed independent practitioners, and non-employee adult students and volunteers should be counted at each facility where they physically work for at least one day from October 1 through March 31. Therefore, you would include this individual in your influenza vaccination summary data reports both for facility A and for facility B. These reports describe influenza vaccination rates among all HCP working at a specific facility, so all eligible HCP must be counted at each facility where they work.
Q6. There are three facilities within our healthcare system. Can I collect and enter a single report of HCP influenza vaccination summary data for our system since many of our staff members work at multiple facilities?
No, each of the system’s facilities need to be enrolled as separate facilities in NHSN and to report their HCP influenza vaccination summary data separately. If an individual physically works in multiple facilities in the healthcare system for at least 1 day from October 1 through March 31, this individual should be counted in the total number of HCP for each facility where they work.
Q7. Should I include an employee who starts working at my facility or unit after October 1, or leaves their position after October 1, in my HCP influenza vaccination summary report?
Yes. All employees, non-employee licensed independent practitioners, and non-employee students and volunteers aged 18 and older who physically work at the facility or unit for at least 1 day from October 1 through March 31, regardless of exact stop or start dates, should be included in HCP influenza vaccination summary data reports.
Q8. In the protocol for collecting HCP influenza vaccination summary data, licensed independent practitioners are defined as physicians, advanced practice nurses, and physician assistants who are affiliated with the reporting facility or unit but are not directly employed by it. What does it mean for HCP to be “affiliated with” a facility or unit?
HCP who are affiliated with the healthcare facility or unit are those who perform a work duty in the facility or unit but are not directly employed by the facility (i.e., they do not receive a paycheck from the facility). This would include non-employee HCP who come into the healthcare facility or unit to round on patients, perform procedures, take facility-required trainings, or undertake other work duties.
Q9. How is a facility owner, particularly a physician owner, categorized for purposes of HCP influenza vaccination summary reporting?
Any owner, even a physician owner, is categorized as an “employee” and included in this measure if he/she is physically working in the facility for at least 1 day from October 1 through March 31.
Q10. Should physician fellows and residents be included in HCP vaccination summary reports?
Yes. Physician fellows (post-residency) are categorized as licensed independent practitioners, unless they are paid directly by the facility, in which case they are employees. Residents and interns not on the facility’s payroll are categorized as adult students/trainees.
Q11. When are advanced practitioners counted as “employees” and when are they counted as “licensed independent practitioners”?
An “employee” is anyone on the payroll of or receiving a paycheck from the facility, regardless of their job duties. Licensed independent practitioners working at the facility for at least 1 day from October 1 through March 31 who do not receive a paycheck directly from the facility should be counted in the “non-employee, licensed independent practitioners” category which includes physicians, advanced practice nurses, and physician assistants. Post-residency fellows are also included in this category, unless they are paid directly by the facility, in which case they are employees.
Q12. Should I count a licensed independent practitioner who rarely comes into a facility or unit during the influenza season?
This person would be included in the HCP influenza vaccination summary data report if they physically work in the facility or unit for at least 1 day from October 1 through March 31.
Q13. Should I include licensed independent practitioners who work in the facility or unit under a contract in my HCP influenza vaccination summary report?
Yes. It is necessary to track contracted physicians, advanced practice nurses, and physician assistants and report them as licensed independent practitioners. Other types of contract personnel who do not meet the definition of a licensed independent practitioner can be reported in the optional “other contract personnel” category if desired. This category includes licensed or credentialed providers other than physicians, advanced practice nurses, and physician assistants who work under a contract with the reporting facility.
Q14. Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included in HCP influenza vaccination summary reports?
No; reporting influenza vaccination summary data for these HCP is not required. Non-licensed contract personnel can be reported in the optional “other contract personnel” category if desired.
Q15. Vendors or sales representatives occasionally come into my facility or unit and may be present during surgeries or other patient care activities. Should we count these vendors in the optional other contract personnel category?
Previously, NHSN instructed facilities not to include vendors as healthcare personnel. After receiving stakeholder feedback, NHSN updated the vaccination reporting guidance to include vendors in the OCP category, regardless of clinical responsibility or patient contact. Therefore, beginning with the 2022-2023 influenza season, vendors providing care, treatment, or services should be included in the other OCP category if they physically work in the facility for at least one day during the reporting period (October 1 through March 31). Please note that data reporting for the OCP category remains optional at this time.
Q16. Should students who work a half-day shift for one day during the reporting period be included in HCP influenza vaccination summary data reports?
Yes. Working any part of a day counts as working 1 day, so you would count these students since they worked at least 1 day from October 1 through March 31.
Q17. Should I count instructors who accompany students to a healthcare facility or unit if the instructors do not otherwise work at the facility or unit?
Yes, you would count these individuals in your HCP influenza vaccination summary data as adult students/trainees and volunteers since they are in the facility or unit to provide instruction to the students/trainees.
Q18. High school students who are age 18 or older can volunteer at our facility or unit. Should these students be counted, or do we only report vaccination among health professional students?
All students/trainees and volunteers aged 18 and over should be counted if they are physically in the facility or unit for at least 1 day from October 1 through March 31. It does not matter if the student is in high school, college, medical school, etc.
Q19. How should we count ‘shadowers’ who visit our facility or unit on a short-term basis to explore a possible career in healthcare? Would they be counted as students/trainees? Most of them are not enrolled in school when they visit.
You would not count shadowers who are touring the facility or unit since they are not in the facility or unit for a work-related or training-related purpose; however, CDC encourages these individuals to obtain influenza vaccination since they have potential exposure to infectious agents including influenza while in the facility or unit. The adult students/trainees and volunteers category should include only current medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older who are affiliated with the facility or unit for work or training purposes (e.g. clinical rotations).
Q20. Should clergy members be included in our facility or unit’s HCP influenza vaccination summary reports?
Yes. If they are physically in the facility or unit for at least 1 day from October 1 through March 31, any unpaid personnel who are in the facility in a formal capacity (clergy member, board member, auxiliary member, etc.) are considered volunteers and should be counted in your summary vaccination report.
Q21. There are some HCP who work in the facility or unit as part-time employees during the day and work as students by night. How should I classify these individuals?
The following hierarchy should be used to classify HCP at your facility or unit: if a healthcare worker (HCW) who works in the facility or unit is on payroll, they should be counted as an employee (even if they work as a student or volunteer at other times). If a HCW is not on the facility payroll, you should determine whether they meet the definition of a licensed independent practitioner. If not, you should finally determine whether the HCW is an adult student/trainee or volunteer. If none of those are the case, then you do not need to count that HCW in your HCP influenza vaccination summary report.
Q22. My healthcare system uses multiple payrolls. Should I count corporate employees of the facility or unit who are paid through a corporate payroll in the employee category for HCP influenza vaccination reporting purposes?
Some healthcare systems use multiple payroll systems; for example, certain individuals within a particular facility or unit may be corporate employees paid directly through a corporate payroll, while others at the facility or unit are facility employees paid directly through a facility payroll. For healthcare systems using multiple payroll systems, a facility or unit would only count as employees those personnel who are paid directly through a facility payroll. Corporate employees who are not paid directly through the facility payroll would not be counted in the employee category, although they could be counted in the licensed independent practitioner or other contract personnel categories if they meet NHSN protocol definitions for either group. However, if a facility or unit is part of a system that has only one payroll for the entire system, then each facility or unit in that system would count all personnel on payroll in the employee category, if they physically work in that facility or unit for at least 1 day from October 1 through March 31.
Q23. What does it mean when it is stated on the HCP Influenza Vaccination Summary Form that “denominators are to be calculated separately for the three required categories”?
The instruction to calculate the denominator data separately means that a facility or unit is required to count and report the number of employees, licensed independent practitioners, and adult students/trainees and volunteers separately instead of reporting a total number of HCP working at the facility. That way, vaccination rates can be determined for each of the three groups. For example, to determine the vaccination rate for employees, you would divide the number of employees who were vaccinated by the total number of employees who worked in your facility or unit for at least 1 day from October 1 through March 31. You would then multiply this by 100 to obtain a percentage.
HCP Categories: Acute Care Facility
Q1. My acute care hospital owns several outpatient provider practices that are physically separate from the main hospital campus and have separate CCNs. Employees of these clinics are on the hospital’s payroll, so should I include them in HCP influenza vaccination summary report for the hospital?
No. Because the practices have separate CCNs, these employees should not be counted in HCP influenza vaccination summary reports for the acute care facility unless they also physically work in the acute care hospital for at least 1 day from October 1 through March 31.
Q2. My facility has an administrative building that is physically connected to the acute care facility by a skywalk. This building is only used for administrative duties and not patient care. Should I count HCP working in this building in the HCP influenza vaccination summary report for my acute care facility?
Yes, you should count HCP working in the administrative building, as it is considered part of the acute care facility.
Q3. Should HCP who are employees of a healthcare system (e.g., university employees), but who are not hospital employees, be included in the acute care facility HCP influenza vaccination summary report?
Non-hospital employees should only be included if they physically work in the acute care facility for at least 1 day from October 1 through March 31 and meet NHSN protocol definitions for either the licensed independent practitioner category or the adult student/trainee and volunteer category. They would not be counted in the employee category since they are not on the hospital’s payroll.
Vaccination Status
Q1. If a HCW was vaccinated at their doctor’s office in August, and worked in the facility during the influenza season, should they be counted as vaccinated in our HCP influenza vaccination summary report?
Yes. This HCW should be counted in the report for your facility, since influenza vaccine for a given influenza season may be available as early as July or August. The strict reporting period for the measure (October 1 through March 31) applies to the denominator. This HCW would be required to provide documentation of influenza vaccination and would be counted in the “vaccinated outside of the healthcare facility” category. If the HCW did not provide acceptable documentation, their vaccination status would be counted as “unknown.”
Q2. What is considered acceptable documentation for a HCW vaccinated outside of the healthcare facility?
Acceptable forms of documentation include a signed statement or form, or an electronic form or e-mail from the HCW indicating when and where they received the influenza vaccine. A note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the HCW received the influenza vaccine at that location is also permitted. Verbal statements are not acceptable to document vaccination outside the facility for the purposes of NHSN HCP influenza vaccination summary data reporting.
Q3. If a HCW can only be reached by phone, and they state they were vaccinated elsewhere, how is this reported?
Their vaccination status is reported as “unknown” unless written documentation is provided. Verbal statements are not acceptable for the purposes of this reporting measure. However, this HCW could send an e-mail or mail a written statement attesting that they were vaccinated outside the facility.
Q4. My healthcare system includes numerous healthcare facilities. A HCW received influenza vaccine within our healthcare system; however, we are unable to identify the specific facility where they were vaccinated. Should this be counted as a vaccination received “at the facility” or “outside the facility”?
If the influenza vaccine was received at any facility within your larger healthcare system and you are unable to determine at which facility they were vaccinated, you can count the HCW as receiving vaccination “at the facility.” Therefore, the HCW would not need to provide written documentation of this vaccination. This only applies to attribution of the influenza vaccine for an individual HCW; facilities are expected to report separate numerator and denominator counts to NHSN for each individual facility in a healthcare system.
Q5. What conditions permit a HCW to be categorized as having a medical contraindication to influenza vaccination?
Only HCP who have a severe allergic reaction to eggs or other components of the influenza vaccine or a history of Guillain-Barré Syndrome (a severe paralytic illness, also called GBS) within 6 weeks after a previous influenza vaccination should be counted as having a medical contraindication to vaccination for purposes of HCP influenza vaccination reporting in NHSN.
Q6. Is documentation required for medical contraindications or vaccine declinations?
No. Documentation is not required for reporting a medical contraindication or a declination; therefore, verbal statements are acceptable for reporting these numerator categories. Documentation is only required for HCP vaccinated outside the reporting facility.
Q7. How should I categorize a volunteer who was offered influenza vaccination, but verbally refused vaccination and stated they had an egg allergy with history of an anaphylactic reaction?
The volunteer should be categorized as having a medical contraindication. Written documentation is not required for medical contraindications.
Q8. How do I categorize HCP who report that they have a medical contraindication but do not confirm that it is one of the two conditions defined as contraindications for NHSN reporting purposes?
They should be reported as “declined to receive the influenza vaccine.”
Q9. My facility offers the live attenuated influenza vaccine (LAIV4) to HCP who do not want to receive an injection. Are the acceptable medical contraindications the same for LAIV4 as for the inactivated influenza vaccine?
There are several different types of influenza vaccines available for use in adults; each vaccine has different precautions and contraindications for use.
HCP who have a medical contraindication to LAIV4 other than a severe allergic reaction to a vaccine component or history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination should be offered trivalent inactivated influenza vaccine (IIV3) or quadrivalent inactivated influenza vaccine (IIV4) by their facility, if available. If IIV3 or IIV4 is offered but declined because of aversion to an injection, the HCW would be categorized as “declined to receive the influenza vaccine.” Therefore, contraindications to LAIV4 that do not preclude receipt of injectable influenza vaccine are not acceptable medical contraindications for this measure.
Q10. How should I categorize a pregnant HCW who states that her healthcare provider recommended against influenza vaccination?
A HCW who does not receive the influenza vaccine because of pregnancy, or any medical reason other than the two allowable contraindications defined for this measure, should be categorized as “declined to receive the influenza vaccine.”
Q11. How should I categorize HCP who decline vaccination because they are ill at the time the influenza vaccine is initially offered and then never have another opportunity to receive it?
They are reported as “declined to receive the influenza vaccine.”
Q12. How do I categorize a HCW who was granted a religious or personal belief exemption to influenza vaccination according to their facility’s policy?
A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for the HCP Vaccination Module should be categorized as “declined to receive the influenza vaccine.” This is true even if your facility permits religious or philosophical exemptions for influenza vaccination.
Q13. How should I categorize a HCW who received a medical exemption for influenza vaccination under his/her facility’s policy, which permits exemptions for conditions other than those specified in the NHSN protocol?
A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for the HCP Vaccination Module should be categorized as “declined to receive the influenza vaccine.” This is true even if your facility permits medical exemptions for reasons other than those defined in the NHSN protocol. In some cases, HCP who are considered medically exempt from vaccination by the facility where they work will be counted as declining vaccination for the purposes of NHSN reporting. Counting only HCP with specified conditions as having a medical contraindication to influenza vaccination ensures that HCP influenza vaccination data reported to NHSN can be compared across different facilities.
Q14. How should I categorize HCP who never came to a clinic or returned a declination form?
If you were unable to confirm a HCW’s influenza vaccination status for any reason, they should be counted in the “unknown” category.
Q15. If I use a survey to collect the numerator information for my facility’s HCP influenza vaccination summary report, how should persons who did not respond to the survey be counted?
If your facility decides to use a survey to collect vaccination status, HCP who do not respond to the survey should be counted in the “unknown” category. The NHSN HCP influenza vaccination measure was not pilot-tested for use with a survey, and facilities are strongly encouraged to track influenza vaccination data from written records instead of using a survey. Surveys should not be used to collect denominator data.
