Count & review each of your patients Influenza Immunization status as of 02/29/2012

1. Influenza Immunization Data Collection • Count & review each of your patients Influenza Immunization status as of 02/29/2012 • Follow the algorithm • Count each patient only once • DO NOT return this form to the Network office – this is for your QAPI records Total Patient Census as of 02/29/2012 (this is PD and HD combined): ______ Yes Patient was not offered the 2011-12 Influenza Immunization due to facility did not order or order was delayed/unavailable? Tally # of patients: Your tallies must equal your total patient census Box A No Patient received the 2011-12 Influenza Immunization EITHER AT THE FACILITY OR ELSEWHERE ? Tally # of patients: Yes Box B No Tally # of patients: Patient refused the influenza immunization? Yes Box C No Tally # of patients: Patient allergic to the influenza immunization? Yes Box D No Tally # of patients: Patient did not receive due to medical contraindication or physician order Yes Box E No If you have patients not falling into one of these root causes, contact the Network office for technical assistance. Info@nw6.esrd.net / 919.855.0882