Healthcare Worker Influenza Vaccination Report

This report is used to measure the influenza vaccination rates of healthcare workers in facilities throughout Rhode Island. Certain healthcare facilities are required to report vaccination information about their empolyees. In addition to being listed in Rhode Island's immunization rules and regulations for healthcare workers, the facility types that must report are listed below under "Facility Type". Facility types not included in this list do not have to report.

Please complete this report each influenza season by May 15. This report is divided into three sections:

I. Facility information

II. Employee healthcare workers

III. Non-employee healthcare workers

Before submitting this report, please make a separate copy of the information to be submitted.


* Questions 1:

  • Include all healthcare workers who have worked at the facility since October, regardless of clinical responsibility or patient contact.
  • Include both full-timers and part-timers. If a healthcare worker works in two or more facilities, each facility should include the healthcare worker. Count healthcare workers as individuals rather than full-time equivalents.

** Questions 2-5:

  • The sum of the numbers submitted for questions 2-5 should equal the number submitted for question 1.