Dialysis Patient Influenza Vaccination

All Data Collection Forms are Print-only

Survey

• Outpatient Dialysis Center Practices Survey Form – January 2021 (57.500) [PDF – 250 KB]

Monthly Reporting Plan

• Dialysis Component Monthly Reporting Plan form – January 2021 (57.501) [PDF – 100 KB]
  • Customizable form [DOCX – 80 KB]

Denominator Form

• Dialysis Patient Influenza Vaccination Denominator Form – January 2021 (57.506) [PDF – 100 KB]
  • Customizable form [DOCX – 80 KB]

Event Form

• Dialysis Patient Influenza Vaccination Event form – January 2021 (57.505) [PDF – 100 KB]
  • Customizable form [DOCX – 80 KB]