Medium

Available on

Apple Android Windows

Healthcare Worker Influenza Vaccination - NHSN Mobile App

This Healthcare Worker Influenza Vaccination is used to collect specific information on whether a seasonal and/or non-seasonal influenza vaccination was received or declined by the HCW, and the date, time, location and type of vaccination that was administered. A separate form is required for each dose of vaccine. The form also contains information on any adverse reactions experienced as a result of the vaccine. This form should be completed for all HCP.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Healthcare Worker Influenza Vaccination - NHSN Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Facility ID

  • Ico textbox

    Vaccination #

  • Ico textbox

    HCW ID#

  • Ico textbox

    HCW Last Name

  • Ico textbox

    HCW First Name

  • Ico textbox

    HCW Middle Name

  • Ico dropdown

    Gender

  • Ico textbox

    Date of Birth

  • Ico textbox

    Work Location

  • Ico textbox

    Occupation

  • Ico textbox

    Clinical Specialty

  • Ico dropdown

    Performs direct patient care

  • Ico textbox

    Type of vaccination

  • Ico statictext

    Influenza subtype

  • Ico checkbox

    Seasonal

  • Ico textbox

    Years (xxxx-xxxx)

  • Ico checkbox

    Non-seasonal

  • Ico textbox

    Years (xxxx-xxxx)

  • Ico dropdown

    Do you plan to use this information to satisfy federal record-keeping requirements for the admini...

  • Ico dropdown

    Vaccine administered

  • Ico statictext

    If declined for personal reasons (check all that apply)

  • Ico checkbox

    Fear of needles/injections

  • Ico checkbox

    Fear of side effects

  • Ico checkbox

    Perceived ineffectiveness of vaccine

  • Ico checkbox

    Religious or philosophical objections

  • Ico checkbox

    Concern for transmitting vaccine virus to contacts

  • Ico checkbox

    Other

  • Ico textbox

    Specify

  • ...and More!

Related Health Care & Social Services Apps... and they're all free for GoCanvas subscribers!

App Name

Pre-season Survey on Influenza Vaccin...

This Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel is used to collect data on the strategie...

App Name

Healthcare Personnel Safety Reporting...

This Healthcare Personnel Safety Reporting Plan is used to collect data on which modules and which months (if any) the f...

App Name

Healthcare Worker Prophylaxis/Treatme...

This Healthcare Worker Prophylaxis/Treatment – Influenza app is used to collect data on which (if any) antiviral medicatio...

App Name

Healthcare Worker Prophylaxis/Treatme...

This Healthcare Worker Prophylaxis/Treatment – BBF Postexposure Prophylaxis(PEP)is used to collect details of medications ...

App Name

Post-season Survey on Influenza Vacci...

This Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel is used to collect information on the s...

App Name

Healthcare Worker Demographic Data - ...

The healthcare worker demographics app can track a variety of details about nurses, doctors, nursing assistants and other ...

App Name

Healthcare Personnel Safety Component...

This Healthcare Personnel Safety Component Facility Survey is used to collect facility administrative data including total...

App Name

Primary Bloodstream Infection (BSI) -...

This Primary Bloodstream Infection (BSI) app is used to guide and support efforts within hospitals in developing surveilla...

More Information