Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vacci

Form Approved

OMB No. 0920-1317

Exp. Date: 03/31/2026

www.cdc.gov/nhsn

Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents

57.216

(Note: This form is used for the Long-term Care Facility Component).

Page 1 of 1	*Required for saving **conditionally required
Person-Level COVID-19 Vaccination Form – LTC Component Resident
Facility ID*:				Resident ID**
Resident Admission Date*				Resident Discharge Date**
First Name*:				Last Name*:
Gender* (Specify):				Date of Birth*:
Sex at Birth (Specify):				Gender Identity (Specify):
Ethnicity* (Specify):				Race* (Specify):
Vaccine Documentation
Medical Contraindication Date**		Declination Date**: Reason: □ Religious □ Other □ Unknown		Unknown/Other Vaccination Status Date**:
Dose 1 Vaccine Manufacturer Name**		Dose 1 Vaccination Date**	Dose 1 Vaccine NDC Number	Dose 1 Vaccine Lot Number	Dose 1 Vaccine Expiration Date
Dose 2 Vaccine Manufacturer Name**		Dose 2 Vaccination Date**	Dose 2 Vaccine NDC Number	Dose 2 Vaccine Lot Number	Dose 2 Vaccine Expiration Date
Dose 3 Vaccine Manufacturer Name**		Dose 3 Vaccination Date**	Dose 3 Vaccine NDC Number	Dose 3 Vaccine Lot Number	Dose 3 Vaccine Expiration Date
Dose 4 Vaccine Manufacturer Name**		Dose 4 Vaccination Date**	Dose 4 Vaccine NDC Number	Dose 4 Vaccine Lot Number	Dose 4 Vaccine Expiration Date
Dose 5 Vaccine Manufacturer Name**		Dose 5 Vaccination Date**	Dose 5 Vaccine NDC Number	Dose 5 Vaccine Lot Number	Dose 5 Vaccine Expiration Date
Dose 6 Vaccine Manufacturer Name**		Dose 6 Vaccination Date**	Dose 6 Vaccine NDC Number	Dose 6 Vaccine Lot Number	Dose 6 Vaccine Expiration Date
Dose 7 Vaccine Manufacturer Name**		Dose 7 Vaccination Date**	Dose 7 Vaccine NDC Number	Dose 7 Vaccine Lot Number	Dose 7 Vaccine Expiration Date
Dose 8 Vaccine Manufacturer Name**		Dose 8 Vaccination Date**	Dose 8 Vaccine NDC Number	Dose 8 Vaccine Lot Number	Dose 8 Vaccine Expiration Date
Dose 9 Vaccine Manufacturer Name**		Dose 9 Vaccination Date**	Dose 9 Vaccine NDC Number	Dose 9 Vaccine Lot Number	Dose 9 Vaccine Expiration Date
Dose 10 Vaccine Manufacturer Name**		Dose 10 Vaccination Date**	Dose 10 Vaccine NDC Number	Dose 10 Vaccine Lot Number	Dose 10 Vaccine Expiration Date
Vaccination Education Provided: □ Yes □ No Date:				Comments:
Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-1317). CDC XX.XXX V.1 September 2024

2