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Reporting Forms

Exemptions to reporting

A hospital may request an exemption to mandatory reporting in some circumstances. Examples of these are:
  • Facilities which perform less than 20 specific surgical procedures (i.e. laminectomy) may request an exemption from reporting that surgical site infection (SSI).
  • Facilities which have less than 50 central line (CL) days per year may request an exemption from reporting CL-associated blood stream infections (CLABSI).

Healthcare worker influenza vaccination survey

Hospitals, long-term care skilled nursing facilities, and free-standing ambulatory surgical centers are required to report influenza vaccinations, documented contraindications, and informed declination rates for staff in accordance with ORS 442.851 and OARs 333-018-000 through 333-018-0145. All facilities were notified of this reporting requirement in September 2011.
There are three documents to assist in collecting data during the 2013-2014 flu season:
  • Attachment A (pdf) represents the content of the annual healthcare worker influenza vaccination survey.
  • Attachment B (pdf includes definitions for the data fields in the survey form (Attachment A).
  • Attachment C (pdf) ​ is a sample Influenza Consent/Declination form that can be used to support the data to be collected for the survey. Note that influenza vaccination, medical contraindication, and refusal of vaccination must be documented. In addition, if your staff members are vaccinated outside of your facility, you need to document this fact so that these staff can be counted as vaccinated. The sample form in Attachment C provides a means to document this information.
All facilities, even if using NHSN, must complete a survey to fulfill Oregon specific reporting requirements. Please input your facility’s rates before May 19, 2014 using the appropriate survey:
  • Short form survey ​for facilities reporting via NHSN. 
    Facilities may use the National Healthcare Safety Network (NHSN) to answer questions 1 through 6 using the Flu Summary module in the NHSN Personnel Safety Component. Questions 7 through 10 regarding vaccine delivery and promotion strategies will still need to be answered using this short form survey.
  • Long form survey for facilities not reporting via NHSN. Facilities which do not use the National Healthcare Safety Network (NHSN) will answer all 10 questions using this long form survey.
Please contact Dianna Appelgate at or call 971-673-1111 with any questions.