Run Healthcare Worker Influenza Vaccination Compliance Inspection — Free

Inspection Scope and Roster

Inspection period documented

Record the vaccination compliance period being reviewed (for example, current influenza season).

Healthcare worker roster matches inspection population critical (required)

Verify the roster includes all in-scope healthcare workers, including employees, licensed independent practitioners, students, agency staff, and volunteers as applicable.

Yes No N/A

Roster source and date of extraction recorded

Document the source system or roster file used and the date it was extracted.

Applicable policy or SOP referenced

Identify the facility policy governing influenza vaccination, declinations, and documentation retention.

Vaccination Status Verification

Documented influenza vaccination on file for each in-scope worker critical (required)

Confirm each in-scope healthcare worker has documented receipt of the current seasonal influenza vaccine or an approved alternative status.

Yes No N/A

Vaccination date recorded

Record the date vaccination was administered for reviewed records.

Note (optional)

Vaccination documentation includes provider or source verification critical (required)

Verify documentation identifies the administering provider, clinic, pharmacy, or acceptable immunization record source.

Yes No N/A

Vaccination documentation is legible and complete critical (required)

Confirm the record includes worker name, vaccine type or season, administration date, and supporting evidence sufficient for audit review.

Yes No N/A

Accepted evidence type used

Select the primary evidence type used to verify vaccination status.

Note (optional)

Records retained in accordance with retention requirements

Verify vaccination records are retained in the designated system or file location and are retrievable for compliance review.

Yes No N/A

Declinations, Exemptions, and Education

Signed declination form on file for unvaccinated workers critical (required)

Verify a signed declination is present for each worker who did not receive the influenza vaccine and is not otherwise documented as vaccinated.

Yes No N/A

Medical contraindication or exemption documented when applicable critical (required)

Confirm any medical exemption or contraindication is supported by appropriate documentation and approved per policy.

Yes No N/A

Declination reason recorded

Select the documented reason for non-vaccination, if applicable.

Note (optional)

Required influenza education or counseling documented critical (required)

Verify education about influenza risks, vaccine benefits, and declination implications was documented for workers who declined vaccination.

Yes No N/A

Follow-up plan documented for pending declinations or exemptions

Confirm pending cases have a documented follow-up date, owner, or escalation path.

Yes No N/A

Compliance Monitoring and Reporting

Compliance rate calculated for the inspection population critical (required)

Enter the percentage of in-scope healthcare workers with documented vaccination or approved exemption/declination.

Note (optional)

Non-compliant records identified and tracked critical (required)

Verify records missing vaccination, declination, or exemption documentation are listed for follow-up.

Yes No N/A

Corrective actions assigned with due dates critical (required)

Confirm each deficiency has an assigned owner, corrective action, and due date.

Yes No N/A

Leadership or infection prevention reporting completed

Verify compliance results are reported to the appropriate leadership, employee health, or infection prevention stakeholders.

Yes No N/A

Inspector Attestation

Inspector name critical (required)

Enter the name of the person completing the inspection.

Inspector role

Enter the inspector's role or department, such as employee health, infection prevention, or compliance.

Inspection completed date and time critical (required)

Record when the compliance inspection was completed.

Inspector signature critical (required)

Signature confirming the inspection findings are accurate and complete.

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Run: Healthcare Worker Influenza Vaccination Compliance Inspection

Inspection Scope and Roster

Vaccination Status Verification

Declinations, Exemptions, and Education

Compliance Monitoring and Reporting

Inspector Attestation

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