Zone:
Seasonal Influenza Immunization Summary Sheet
2016-2017 Season
(FOR PUBLIC HEALTH SERVICES USE)
INTRODUCTION
The following tables are to be used to aggregate all the separate tables from Public Health
Clinics, Long Term Care/ Residential Care Facilities and all other facilities and clinics in the zone.
This summary sheet is divided into 4 parts.
Part 1: Summary of the data for all Long Term Care / Residential Care Facilities.
Part 2: All of the data from Public Health (PH) clinics should have been aggregated into the
provided table (PH Aggregate) at the Public Health Office level. All these tables are to be
summarized in Part 2 of this summary sheet.
Page 3: For Health Care Facilities (excluding Long Term Care / Residential Care Facilities) that
administer influenza vaccine to staff or volunteers, the data will be summarized in Part 3.
Part 4: All Other Facilities/Clinics should summarize all other facilities/clinics that did not have
coverage rates for staff/volunteers or patients/residents (e.g. community clinics).
The zone should only submit one summary sheet to the DHW Surveillance Team, and should
make sure it includes data from all facilities and clinics in the zone.
Please complete all parts and return, by March 31, 2017 to:
DHW Surveillance Team
Fax: 902-424-0550 or E-mail: [email protected]
2016-2017 INFLUENZA DATA COLLECTION TOOLS
Influenza Immunization Summary Sheet
Page 1 of 5
Zone:
Part 1
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Long Term Care/Residential Care Facilities in the Zone
The data categories are all broken down into 3 sections. 'Facility Coverage Rates' is the data that will be necessary for you
to calculate the coverage rates in your facility, 'Age Groups' and 'Target Groups' will be necessary for the DHW Surveillance
Team to collect coverage rates of the specified target groups provincially
'Number in Facility'(A) is a count of all people who fall under each category (the denominators)
'In House' (B) is the number of individuals who received an influenza vaccine by the immunization provider
within the facilities
'Other Provider' (C) is the number of staff, volunteers, and residents/patients who have received an influenza
vaccine from outside the facilities (e.g. family physician)
‘Total’ (D) is the sum of individuals vaccinated ‘In House’ (B) and by ‘Other Provider’ (C) -- (D=B+C)
'All Other' category is intended to capture individuals who are not residents/patients or staff and volunteers but who
received vaccine from all facilities
In addition to the total number vaccinated, you must also record the data for each target group for those immunized 'In
House'
'Total # Vaccinated' - must be broken down into age categories
The number of facilities (by type), the number of facilities (by type) with complete forms, and number of facilities in the
zone that met the target coverage rate (tally of checked boxes) are reported in the boxes at the bottom of the form.
Number
in
Facility
(A)
DATA CATEGORIES
#Immunized
Other
Provider
(C)
Total
(D)
%
Immunized
(E)
-
-
-
-
-
-
-
-
In
House
(B)
Staff
Volunteers Total
Facility
Coverage
Rates
Residents/Patients Total
All Other Total
TOTAL # VACCINATED INHOUSE
(In column ‘B’ only)
Breakdown
total #
vaccinated
in-house
Column B
by age
Target
Groups
6-23 mos
2-4 yrs
5-17 yrs
18-23 yrs
24-64 yrs
Pregnant Total
-
-
-
-
Aboriginal Living on Reserve Total
-
-
-
-
#Long Term Care Facilities
#Facilities (Physician administered vaccine)
#LTC Facilities with complete forms
#Facilities (Nursing staff administered vaccine)
#Residential Care Facilities
#Facilities (Pharmacist administered vaccine)
#RC Facilities with complete forms
#Facilities (Other administered vaccine)
≥65 yrs
#Facilities Met Target Coverage Rate (95%)
2016-2017 INFLUENZA DATA COLLECTION TOOLS
Influenza Immunization Summary Sheet
Page 2 of 5
Zone:
Part 2
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Public Health Clinics in the Zone
This table is to summarize only doses administered in Public Health Clinics, in the zone
'Total Number Vaccinated' is a count of all people who were vaccinated in Public Health Clinics, in the zone
In addition to the total number vaccinated in Public Health Clinics, you must also record the data for each age
and target group
The sum of all those in 'Age Groups' should equal the 'Total # Vaccinated'
TOTAL # VACCINATED
Age and target groups vaccinated in PH clinic(s) in zone
6 – 23 mos Total
2 – 4 yrs Total
5 – 17 yrs Total
Age Groups
(Sum should equal ‘Total # Vaccinated’)
18 – 23 yrs Total
24 – 64 yrs Total
≥65 yrs Total
Pregnant Total
Target Groups
2016-2017 INFLUENZA DATA COLLECTION TOOLS
Aboriginal Living on
Reserve Total
Influenza Immunization Summary Sheet
Page 3 of 5
Zone:
Part 3
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Heath Care Facilities Immunizing Staff/Volunteers (excluding
LTCFs) in the Zone
This table is to summarize all doses administered outside of LTCFs/RCFs and PH clinics, in the zone, in health care facilities
with staff/volunteers
The data categories are all broken down into 3 sections. 'Facility Coverage Rates' is the data that will be necessary to
calculate the coverage rates among staff/volunteers in the facilities, 'Age Groups' and 'Target Groups' will be necessary for
DHW Surveillance Team to collect and report coverage rates provincially
'Number in Facility'(A) is a count of all staff and volunteers who work in the facilities in the zone (the denominator)
'In House' (B) is the number of individuals who received an influenza vaccine by the immunization provider
within the facilities/clinics
'Other Provider' (C) is the number of staff and volunteers, who have received an influenza vaccine from outside
the facility (e.g. family physician). ‘Total’ (D) is the sum of individuals vaccinated ‘In House’ (B) and by ‘Other
Provider’ (C) -- (D=B+C)
'Total # Vaccinated' is intended to capture all individuals who received an influenza vaccine from your facilities/clinics in
the zone (patients, staff, volunteers etc.)
In addition to the total number vaccinated, record the data for each age and target group of those immunized 'In House'
'Total # Vaccinated' – must be broken down into age categories
The number of facilities with complete forms and number of facilities with incomplete forms are also provided in the boxes
at the bottom of the form.
Number
in
Facility
(A)
DATA CATEGORIES
#Immunized
Other
Provider
(C)
Total
(D)
%
Immunized
(E)
--
--
--
--
--
--
--
--
In
House
(B)
Staff
Volunteers Total
Facility
Coverage
Rates
Residents/Patients Total
All Other Total
TOTAL # VACCINATED INHOUSE
(In column ‘B’ only)
Breakdown
total #
vaccinated
in-house
Column B
by age
Target
Groups
6-23 mos
2-4 yrs
5-17 yrs
18-23 yrs
24-64 yrs
≥65 yrs
Pregnant Total
--
--
--
--
Aboriginal Living on Reserve Total
--
--
--
--
#Facilities/Clinics with completed forms
2016-2017 INFLUENZA DATA COLLECTION TOOLS
#Facilities/Clinics with incomplete forms
Influenza Immunization Summary Sheet
Page 4 of 5
Zone:
Part 4
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All Other Facilities/Clinics (Non-PH and Non-Health Care
Facilities) in the Zone
This table is to summarize all doses administered outside of LTC and PH clinics in the zone for
facilities/clinics not immunizing staff/volunteers or patients/residents of health care facilities
'Total Number Vaccinated' is a count of all people who were vaccinated in these facilities and clinics in
the zone
In addition to the total number vaccinated, you must also record the data for each age and target
group
The sum of all those in 'Age Groups' should equal the 'Total # Vaccinated'
TOTAL # VACCINATED
Age and target groups vaccinated in all other clinics in zone
6 – 23 mos Total
2 – 4 yrs Total
Age Groups
(Sum should equal ‘Total #
Vaccinated’)
5 – 17 yrs Total
18 – 23 yrs Total
24 – 64 yrs Total
≥65 yrs Total
Pregnant Total
Target Groups
2016-2017 INFLUENZA DATA COLLECTION TOOLS
Aboriginal Living on
Reserve Total
Influenza Immunization Summary Sheet
Page 5 of 5