Annual Influenza and COVID-19 Vaccination Reporting

This form is for the submission of health care personnel (HCP) vaccination data for clinics, emergency medical services (EMS), and hospice programs licensed by the Massachusetts Department of Public Health. Data should be submitted once per respiratory virus season by December 31.

Hospitals, ambulatory surgical centers, dialysis centers, and nursing homes should report this data through the National Health Saftey Network (NHSN).

Rest homes and Adult Day Health programs should report this data using the Health Care Facility Reporting System (HCFRS).

Select the respiratory virus season you are submitting data for.

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Oct 1 2023 - Dec 31 2023

Oct 1 2024 - Dec 31 2024

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Select the type of facility or service you are reporting data for.

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Clinic or clinic satellite

Mobile/portable clinic

Emergency medical service

Hospice program

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Select the clinic you are submitting data for.

Note: You may type your 4-character DPH ID or facility name to search in the dropdown list, or scroll through the list, which is alphabetized by facility name. If you do not see your facility listed, please scroll to the end and select OTHER.

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Select the mobile clinic you are submitting data for.

Note: You may type your 4-character DPH ID or facility name to search in the dropdown list, or scroll through the list, which is alphabetized by facility name. If you do not see your facility listed, please scroll to the end and select OTHER.

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Select the emergency medical service you are submitting data for.

Note: You may type your service name to search in the dropdown list, or scroll through the list. If you do not see your service listed, please scroll to the end and select OTHER.

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Select the hospice program you are submitting data for.

Note: You may type your DPH ID or program name to search in the dropdown list, or scroll through the list, which is alphabetized by program name. If you do not see your program listed, please scroll to the end and select OTHER.

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You selected "Other." Enter your facility or service name.

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You selected "Other." Enter your facility's DPH ID.

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You selected "Other." Enter your service number.
If you have questions about your service number, please email matthew.h.blackburn@mass.gov.

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Please provide the vaccination or exemption status for all health care personnel (HCP) who worked in your facility or service at least 1 day during this respiratory virus season: ______. All questions must be completed. If no HCP fall in a particular category then please enter "0".

NOTE: HCP means an individual or individuals who either work at or come to the licensed provider and who are employed by or affiliated with the provider, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers, whether or not such individual(s) provide direct care.

How many total health care personnel (HCP) worked at least 1 day at this facility or service during this respiratory virus season?

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Influenza Vaccination
Please ensure that the following categories add up to the total number of HCP reported above. The sum of your responses is shown to the right.
How many HCP during this respiratory virus season received an influenza vaccine (at your facility or elsewhere)?
How many HCP during this respiratory virus season are exempt from influenza vaccination?

COVID-19 Vaccination
Please ensure that the following categories add up to the total number of HCP reported above. The sum of your responses is shown to the right.
How many HCP are up to date* with COVID-19 vaccination during this respiratory virus season?
How many HCP are exempt from COVID-19 vaccination during this respiratory virus season?

*Up to date with vaccine doses for COVID-19 means that HCP must receive one updated COVID-19 vaccine. Updated COVID-19 vaccine means one dose of the updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine. If an individual has never received a COVID-19 vaccine in the past, they should receive 2 doses of Novavax to be considered up to date. Please refer to the CDC website for additional details: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html

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