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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.


Technical Note: There is a size limit on the number of characters that can be entered/pasted into the two text areas at the end of the form. If the form fails to execute properly after hitting "Send to IAC" try entering less text and sending any additional information via email to admin@immunize.org.

 
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 July 6, 2019.
This page was reviewed on July 6, 2019.
 
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