Home
|
About IAC
|
Contact
|
A-Z Index
|
Donate
|
Shop
|
SUBSCRIBE
Immunization Action Coalition
IAC Home
|
Honor Roll
|
Influenza Vaccination HCP Honor Roll
|
Application for Enrollment

Apply for the Influenza Vaccination Honor Roll

Tell Us about Influenza Vaccination Mandates for Healthcare Personnel

IAC is recognizing healthcare settings that have mandated influenza vaccination for their staff with the goal to protect their patients. Honorees include healthcare systems, hospitals, medical practices, pharmacies, and many others. Patient well-being and safety is more important than the personal preference of an individual staff member's choice to not get vaccinated.

CRITERIA FOR INCLUSION: To be included in the Influenza Vaccination Honor Roll, the mandate you are reporting must require influenza vaccination for all staff and, in addition, must include measures to prevent transmission of influenza from unvaccinated personnel to patients. Such measures might include a masking requirement for the entire work shift, reassignment to non-patient-care duties, or dismissal of the staff member.

Fill out this form and then click the "Send to IAC" button at the bottom of the page.

 
Contact Information
PLEASE NOTE THAT ALL SECTIONS IN ORANGE ARE REQUIRED.
Your First Name:  
Your Last Name:  
Degree(s):  
Job Title:  
Organization Name:
(that is implementing the mandate)
 
Organization Type:
"Other" Org. Type or State Name:  
Street1:  
Street2:  
City:  
State:  
Zip Code:  
Your Phone:  
Email Address:  
Confirm Email Address:  
Second Email Address:  
Confirm 2nd Email Address:  
Mandate Information

Has your organization been listed on the Honor Roll
previously? Check IAC's list of existing honorees for
your institution. Are you already listed?

 
   Yes  No
  If Yes, then you do not need to reapply.

Additional information you wish to share:

 

Can staff opt out of receiving influenza vaccination
for MEDICAL reasons?

 
 Yes  No  Don't Know

Please indicate which consequences apply
if the staff person refuses vaccination for
MEDICAL REASONS.

Check all that apply:

 
 Reassignment
 Wearing a mask
 None
 Don't know
 Other. Please specify:
 

Can staff opt out of receiving influenza vaccination
for RELIGIOUS reasons?

 
 Yes  No  Don't Know

Please indicate which consequences apply
if the staff person refuses vaccination for
RELIGIOUS REASONS.

Check all that apply:

 
 Dismissal
 Reassignment
 Wearing a mask
 None
 Don't know
 Other. Please specify:
 

Can staff opt out of receiving influenza vaccination
for reasons OTHER THAN MEDICAL OR RELIGIOUS?

 
 Yes  No  Don't Know

Please indicate which consequences apply
if the staff person refuses vaccination for
OTHER REASONS.

Check all that apply:

 
 Dismissal
 Reassignment
 Wearing a mask
 None
 Don't know
 Other. Please specify:
 

In your healthcare setting, what are the dates that
wearing a mask begins and ends, and how are
those dates determined?

 

During a work shift, what are the rules determining when
an unvaccinated staff member must wear a mask?

Check all that apply:

 
At all times, in any patient care area or other
area where patients might be located (x-ray
department, laboratory, corridor), with the
exception of break time
Within a certain distance (number of feet)
from a patient. Please provide details:
 
 Only when in a patient room
 Other. Please provide details:
 

Please tell us who is covered by the mandate :
  All healthcare personnel employed

  in the facility

 
 Yes  No  Don't Know

  All healthcare personnel who come into the
  facility to see patients (e.g., all non-hospital-
  based physicians)

 
 Yes  No  Don't Know

  All healthcare personnel with patient contact

 
 Yes  No  Don't Know

  Clerical staff

 
 Yes  No  Don't Know

  Janitorial staff

 
 Yes  No  Don't Know

  Laboratory staff

 
 Yes  No  Don't know  Not applicable

  Dietary staff

 
 Yes  No  Don't know  Not applicable

  Students

 
 Yes  No  Don't know  Not applicable

  People who volunteer in the facility

 
 Yes  No  Don't know  Not applicable

Approximately how many people are covered
by this mandate? (Enter integers only.)

 

What is/was the implementation date?
(Provide precise MM/DD/YY if known.)

 

Please provide any additional information
about the mandate or any additional
comments you would like to share:

 

Please provide Internet links to any
information about the mandate, such as
press releases or organization web page:

 
 

There may be a delay after sending. Please be patient.
You will receive an email message containing a copy of the information entered here.
Thank you for helping with this important project!
 
Internal use only
This page was updated on February 18, 2016
This page was reviewed on February 18, 2016
 
- Guide to immunize.org -
A-Z INDEX
ABOUT IAC
ACIP RECOMMENDATIONS
ADDITIONAL RESOURCES
ADULT VACCINATION
ADULT VACCINATION GUIDE
ADULT VACCINATION
RESOURCES LIBRARY (AVRL)
ASK THE EXPERTS
Combination Vaccines
Diphtheria
Hepatitis A
Hepatitis B
Question of the Week
Vaccine Storage and Handling
What's New
>> view all
BIRTH DOSE GUIDEBOOK
CALENDAR
CDC SCHEDULES
CLINIC RESOURCES
Administering Vaccines
Documenting Vaccination
Scheduling Vaccination
Screening for Contraindications
Storage & Handling
Vaccine Recommendations
>> view all
COALITIONS
COCOONING
CONTINUING EDUCATION
CONTRIBUTE TO IAC
DEAR COLLEAGUE LETTER
HPV VACCINE
DEAR COLLEAGUE LETTER
MCV4 DOSE #2
DISEASES & VACCINES
Diphtheria
Hepatitis A
Hepatitis B
Influenza
Varicella
>> view all
DONATE TO IAC
EDUCATIONAL MATERIALS
FAQs
FDA PRODUCT APPROVALS
GIVE BIRTH TO THE END OF
HEP B
HANDOUTS FOR PATIENTS &
STAFF
Administering Vaccines
Adult Vaccination
Documenting Vaccinations
Medical Management
Parent Handouts
Patient Schedules
Questions & Answers
Recommendations
Screening Questionnaires
Standing Orders
Storage & Handling
Supplies Checklist
Talking with Parents
Temperature Logs
Translations
Vaccine Index
Vaccine Reactions
>> view all
HEPATITIS B BIRTH DOSE
HONOR ROLLS
HepB Birth Dose
Influenza Vaccination for HCP
IAC EXPRESS
IMAGES
IMMUNIZATION TECHNIQUES DVD
IMMUNIZATION TOPICS
Adoption
Healthcare Personnel
Mandates & Exemptions
Pregnancy
Tattoos & Piercings
>> view all
 
LAMINATED SCHEDULES
NEEDLE TIPS
NEWS & INFORMATION
OFFICIAL RELEASES
ACIP
CDC
FDA
>> view all
PACKAGE INSERTS
PHARMACISTS
PHOTOS
POCKET GUIDES
POWERPOINT SLIDE SETS
PRESS ROOM
PROTECT NEWBORNS
FROM HEP B
PUBLICATIONS
IAC Express
Needle Tips
Vaccinate Adults
THE PURPLE BOOK
QUESTION OF THE WEEK
REGISTRIES
RESOURCE DIRECTORY
SCHOOL-LOCATED VACCINATION
SHOP IAC
Immunization Techniques DVD
Laminated Schedules
Patient Record Cards
The Vaccine Handbook
>> view all
SITE MAP
SLIDE SETS
STATE INFORMATION
State Websites
State Laws
State Immunization Managers
>> view all
SUBSCRIBE
SUPPORT IAC
TECHNICALLY SPEAKING
TRANSLATE FOR IAC
TRAVEL (INTERNATIONAL)
UNPROTECTED PEOPLE REPORTS
Chickenpox
Diphtheria
Hepatitis A
Hepatitis B
>> view all
VACCINATE ADULTS
VACCINE CONCERNS
Adjuvants & Ingredients
Alternative Medicine
Autism
Importance of Vaccination
>> view all
THE VACCINE HANDBOOK
VACCINE INFORMATION STATEMENTS
Translations
Vaccine Index
>> view all
VACCINE POLICY & LICENSURE
ACIP
FDA
WHO
>> view all
VACCINE SAFETY
VACCINES & DISEASES
VIDEOS (VIDEO OF THE WEEK)
WHAT'S NEW OR UPDATED AT IAC
Handouts
VISs
Web Sections
>> view all
 
Immunization Action Coalition  •  2550 University Avenue West  •  Suite 415 North  •  Saint Paul, Minnesota  •  55114
tel 651-647-9009  •  fax 651-647-9131
 
 
 
This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 6NH23IP22550) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.