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State of California—Health and Human Services Agency
California Department of Public Health

AFL 13-02
March 1, 2013

General Acute Care Hospitals

Revised Procedures for Mandated Reporting of Healthcare Personnel Influenza Vaccination

AUTHORITY:      Health and Safety Code (HSC) Section 1288.7 and 1288.8

​This All Facilities Letter (AFL) serves to notify general acute care hospitals (GACHs) of revised California Department of Public Health (CDPH) procedures for accepting hospital healthcare personnel (HCP) influenza vaccination rate reporting data as required under HSC Section 1288.7 and 1288.8.

Beginning with the 2012-2013 influenza reporting period (October 1, 2012 through March 31, 2013), hospitals must report using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Healthcare Personnel Vaccination Summary reporting module. Paper forms will not be accepted by CDPH via fax or mail. Additionally, NHSN’s The Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel will replace the annual CDPH survey previously administered through Survey Monkey.

HCP influenza vaccination reporting in NHSN consists of a single data entry screen per influenza season, so each time a hospital enters updated HCP data for a particular influenza season, all previously entered data for that season will be overwritten and a new modified date will be auto-filled by the system. Entering a single final HCP Influenza Vaccination Summary report via NHSN at the conclusion of the influenza season will meet CDPH requirements. To fulfill the state reporting requirement, each hospital’s reporting for the October 1 through March 31 influenza season must be completed by May 15 each year.

Reportable HCP categories include:

  • Employees HCP (employees are staff on facility payroll)
  • Non-Employee HCP (Licensed Independent Practitioners, Physicians, Advanced Practice Nurses and Physician Assistants)
  • Non-Employee HCP (Adult Students/Trainees and Volunteers)
  • Non-Employee HCP (Other/Contract Personnel)

Hospitals should note that the NHSN "Non-Employee HCP" category includes Registry Personnel, such as nurses contracted through agencies or travel employers, for which hospitals have been reporting influenza vaccination rates to CDPH since the 2011-12 influenza season. For a list of other Contract HCP to include in this category, please see Appendix A:

CDC - Manual for the Surveilance of Vaccine-Preventable Diseases

For each HCP category, data must be compiled for the influenza reporting period, October 1 through March 31 each year.

  • The denominator: HCP who have worked at the facility for at least 30 working days during the reporting period, regardless of clinical responsibility or patient contact. Only HCP physically working in the facility for at least 30 days between October 1 and March 31 should be counted. Denominators are to be calculated separately for each HCP category.
  • The numerator: HCP in the denominator population, who during the time from when the vaccine became available (e.g., August or September) through March 31 of the following year:
    a. received an influenza vaccination administered at the healthcare facility; or
    b. provided documentation that influenza vaccination was received elsewhere; or
    c. were determined to have a medical contraindication/condition of severe allergic reaction to eggs or other component(s) of the vaccine, or history of Guillain-Barré Syndrome (GBS) within 6 weeks after a previous influenza vaccination; or
    d. were offered but declined influenza vaccination(1); or
    e. had an unknown vaccination status or did not otherwise meet any of the definitions of the above-mentioned numerator categories.

If the hospital staff members responsible for HCP influenza vaccination reporting do not currently have NHSN access, they can be added as users by the hospital’s existing NHSN Administrator. All personnel responsible for reporting must complete the online NHSN training, including the pre-recorded webinars, available at:

CDC - National Health Care Safety Network Webinars: Health care Personnel Vaccination

More information about NHSN HCP Influenza Vaccination reporting protocols and instructions is available online at:

CDC- National Health Care Safety Network: Surveillance for Health Care Personnel Vaccination

Questions related to NHSN reporting can be sent via e-mail to (please include "HCP Flu Summary" in the subject line).

Additional guidance and assistance is also available through the CDPH Healthcare Associated Infections (HAI) Program, via phone at (510) 412-6060 or email at



Original signed by Debby Rogers

Debby Rogers, RN, MS, FAEN
Deputy Director  


1 A model vaccination declination form is available on the CDPH HCP influenza vaccination site: Coming Soon. While NHSN does not require hospitals to provide documentation for employee declinations, California Health and Safety Code Section 1288.7 does.


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