- Sample FORMS/RESOURCES -
Influenza Virus Vaccine Roster
Provider Name: ______
Provider Number: ______
Date of Service: ______
Patient’s Health Insurance Number / Patient’s Name / Patient’s Address / Date of Birth / Sex M/F / Patient’s Signature or Stamped “Signature on file”Last / First / MI
PNEUMOCOCCAL PNEUMONIA Vaccine Roster
Provider Name: ______
Provider Number: ______
Date of Service: ______
Patient’s Health Insurance Number / Patient’s Name / Patient’s Address / Date of Birth / Sex M/F / Patient’s Signature or Stamped “Signature on file”Last / First / MI
WARNING: Ask beneficiaries if they have been vaccinated with PPV.
* Rely on patient’s memory to determine prior vaccination status.
* If patients are uncertain whether they have been vaccinated within the past years, administer the vaccine.
* If patients are certain that they have been vaccinated within the past 5 years, do not vaccine
SAMPLE INTRODUCTORY LETTER TO COMMUNITY/SENIOR CENTERS
[Date]
[Name]
[Title]
[Community/Senior Center Name]
[Street Address]
[City/State/Zip]
Dear [Name]:
The influenza season is coming and you’re probably already concerned about the impact that the flu can have on our community.
Here are some facts about the flu:
· Each year in the United States more than 330,000 people are hospitalized and more than 41,000 die from influenza and its complications
· Each worker who gets influenza misses an average of three to four workdays
· When children get the flu, they end up staying home from school an average of three days and, as a result, their parents miss almost a full day of employment, appointments, event participation, or volunteer work
Here’s the good news. Vaccination against influenza can help:
· Reduce absenteeism due to influenza by 57%
· Prevent hospitalization and reduce the risk of death from the disease
· Reduce doctor visits due to upper respiratory illness up to 44%
· Save health care costs for our local businesses and non-profits; in healthy working adults, approximately $47.00 per vaccinated employee can be saved due to decreased sick leave.
That’s why [insert your pharmacy name] is organizing an influenza vaccination program this fall. Through this program, members of our pharmacy staff will come to your community center, at dates and times you choose, to give flu vaccinations to your citizens.
The cost of an influenza shot is [insert pharmacy’s cost]. Your members or visitors can pay for the vaccinations themselves (out-of-pocket, seeking reimbursement from insurers), or [insert community/senior center name] might consider subsidizing some or all of the expense as part of its community service. Either way, you could promote this program as a convenient service to your constituents and as a benefit to the community as a whole.
Our pharmacy and its staff will make all the arrangements for this event. We will set up a vaccination clinic in a convenient location at [insert community/senior center name], coordinate the schedule, administer the vaccine safely and efficiently, and manage payment, all with minimal disruption to your daily routines.
Flu season will be here soon. It’s in your community center’s interest to help protect visitors and members against this potentially serious disease. Please contact me as soon as possible to discuss how we can assist by arranging a community vaccination event.
Sincerely,
[Your name]
[Contact information]
SAMPLE INTRODUCTORY LETTER TO EMPLOYERS
[Date]
[Name]
[Title]
[Company Name]
[Street Address]
[City/State/Zip]
Dear [Name]:
The flu season is coming. And you’re probably already concerned about the impact that influenza can have on your company’s productivity:
· Each worker who gets sick with the flu misses an average of three to four workdays
· Those who come to work sick with influenza are less productive – and they pose a risk of infecting others, who in turn will call in sick
· When children get the flu, parents must often stay home to take care of them, thus missing even more workdays – even though they themselves aren’t sick
Here’s the good news. Vaccination against influenza has been calculated to:
· Reduce workdays lost due to influenza by 57%
· Save your company approximately $47.00 per vaccinated employee due to decreased sick leave and fewer physician visits
· Prevent hospitalization and reduce the risk of death from the disease
That’s why [insert your pharmacy name] is organizing a flu shot program this fall. Through this program, members of our pharmacy staff will to come to your workplace, at dates and times you choose, to give influenza vaccinations to your workforce.
The cost of an influenza vaccination is [insert pharmacy’s cost]. Your employees can pay for the vaccinations themselves (out-of-pocket, seeking reimbursement from insurers, or through your flexible spending plan), or your company might consider subsidizing some or all of the expense as part of its health-benefits package. Either way, you could promote this program as a convenient service to your workers and as a benefit to your workplace and to the community as a whole.
Our pharmacy and its staff will make all the arrangements for this event. We will set up a vaccination clinic in a convenient location in your workplace, coordinate the schedule, administer the vaccine safely and efficiently, and manage payment, all with minimal disruption to your workflow.
Flu season will be here soon. It’s in your company’s interest to help protect workers against this potentially serious disease. Please contact me as soon as possible to discuss how we can assist by arranging a workplace vaccination event.
Sincerely,
[Your name]
[Contact information]
SAMPLE PRESS RELEASE
For Immediate Release Contact:
[Date] [Name, Title] [Phone, E-mail Address]
LOCAL PHARMACY PLEDGING TO HELP COMMUNITY STAY HEALTHY
[City, State] — With the flu season fast approaching, [Pharmacy name] at [street address] will offer influenza immunizations to its customers on [date(s)] between [start time] and [end time].
“Influenza and its complications have a huge medical, social, and economic impact on the nation,” said [pharmacist’s name], [company title]. “By making influenza vaccinations available conveniently and efficiently, we’re helping our customers to protect themselves — and the whole community — against this potentially serious disease.”
Influenza statistics underscore why getting vaccinated against influenza is so important. For example, in a typical influenza season in the United States, about 20% of the population get influenza. Also, more than 330,000 people are hospitalized and more than 41,000 die from influenza and its complications.
“Annual vaccination is the single best way to help prevent influenza,” said [pharmacist’s name]. [He/She] added that, because influenza is so contagious, vaccinating as many people as possible helps prevent the spread of the disease to family, friends, and co-workers.
Although October and November are the recommended months for vaccination, a vaccination given later in the season (December through March) can still help protect you from influenza. Influenza season runs from November through February.
Because the US government recommends influenza vaccinations for almost two-thirds of its citizens, pharmacies like [pharmacy name] are expanding their services to help meet demand.
[Pharmacist’s name] said that all pharmacy staff administering influenza vaccinations are fully trained and certified, in compliance with state regulations.
The cost for an influenza vaccination is [price]. To learn out more about the influenza vaccination program, or to schedule a vaccination appointment, call [pharmacy] at [phone number].
SAMPLE PRESS RELEASE FOR COMMUNITY/SENIOR CENTER
For Immediate Release Contact:
[Date] [Name, Title] [Phone, E-mail Address]
INFLUENZA VACCINATIONS AVAILABLE TO THE COMMUNITY
[City, State] — With the flu season fast approaching, the [community/senior center name] at [street address] will be hosting an influenza immunization event for the public on [date(s)] between [start time] and [end time]. The event will be overseen and administered by [pharmacy name] staff, all of whom are fully trained and certified, in compliance with state regulations.
“Influenza and its complications have a significant impact on our community’s health,” said [community center representative name], [title]. “By working with our local pharmacy to make influenza vaccinations available conveniently and efficiently, we can help people protect themselves—and the people they come in contact with—against this potentially serious disease.”
Influenza statistics underscore why getting vaccinated against influenza is so important. For example, in a typical influenza season in the United States, about 20% of the population get influenza. Also, more than 330,000 people are hospitalized and more than 41,000 die from influenza and its complications.
“Annual vaccination is the single best way to help prevent the flu,” said [community center representative name]. [He/She] added that, because influenza is so contagious, vaccinating as many people as possible helps prevent the spread of the disease to family, friends, and neighbors.
Because the US government recommends influenza vaccinations for almost two-thirds of its citizens, more and more pharmacies are expanding their vaccination services to the community to help meet demand.
Although October and November are the recommended months for vaccination, a vaccination given later in the season (December through March) can still help protect you from influenza.
The cost for an influenza vaccination is [price] and the event is open to everyone. To learn out more about [community center’s] influenza vaccination program, or to schedule an influenza vaccination event in your area, call [pharmacy name] at [phone number].
SAMPLE PRESS RELEASE FOR EMPLOYERS
For Immediate Release Contact:
[Date] [Name, Title] [Phone, E-mail Address]
A NEW HEALTH BENEFIT:
LOCAL COMPANY OFFERS WORKERS INFLUENZA VACCINATIONS ON THE JOB
[City, State] — With the flu season fast approaching, [pharmacy name] at [street address] will be hosting an influenza immunization program for its employees on [date(s)] between [start time] and [end time]. The event will be overseen and administered by [pharmacy name] staff, all of whom are fully trained and certified, in compliance with state regulations.
“Influenza and its complications have an impact on corporate health,” said [company representative name], [company title]. “By making flu vaccinations available conveniently and efficiently, we’re helping our employees to protect themselves—and indeed the whole community—against this potentially serious disease.”
Statistics on influenza in the workplace underscore why getting vaccinated against influenza is so important. For example, in a typical influenza season in the United States, influenza can cost a company an estimated three to four lost workdays per person. In addition, annual influenza epidemics result in an average of more than 3 million days of hospitalization and more than 31 million outpatient visits. Direct medical costs of influenza amount to more than $16 billion annually, with a total economic burden (including absenteeism, lost productivity, and death) of more than $87 billion.
“Annual vaccination is the single best way to help prevent influenza,” said [company representative name]. [He/She] added that, because influenza is so contagious, vaccinating as many people as possible helps prevent the spread of the disease to co-workers, family, and friends.
Because the US government recommends influenza vaccinations for almost two-thirds of its citizens, more and more pharmacies are expanding their vaccination services in the workplace to help meet demand.
The cost for an influenza vaccination is [price] and open only to employees of [company name] and their families. To learn more about [company name’s] influenza vaccination program, or to schedule an event at your workplace, call [pharmacy name] at [phone number].
SAMPLE THANK YOU LETTER TO COMMUNITY/SENIOR CENTERS
[Date]
[Name/Title]
[Company Name]
[Street Address]
[City/State/Zip]
Dear [Name]:
On behalf of [insert your pharmacy name], I want to thank you for participating in our influenza immunization program. By working with us to provide flu vaccinations to your community, you’ve helped us achieve an important goal: helping to prevent as many people as possible from contracting, and spreading, influenza. I’m sure you’ll find that your support of our vaccination efforts translates into better health for your neighborhood during this influenza season.
Keep in mind that even in December and January it’s not too late to vaccinate. People who were unable to get vaccinated during our event should still consider getting their influenza vaccinations. They can contact our pharmacy or speak to their physicians about their options.
If possible, we would appreciate any feedback you can provide that we can incorporate into next year’s program.
Again, thanks. We appreciate the opportunity to provide a valuable service to your community.
Sincerely,
[Your Name]
SAMPLE THANK YOU LETTER TO EMPLOYERS
[Date]
[Name/Title]
[Company Name]
[Street Address]
[City/State/Zip]
Dear [Name]:
On behalf of [insert your pharmacy name], I want to thank you for participating in our influenza immunization program. By working with us to provide influenza vaccinations to your employees, you’ve helped us achieve an important goal: helping to prevent as many people as possible from contracting, and spreading, influenza. I’m sure you’ll find that your support of our vaccination efforts translates into greater productivity and reduced absenteeism during this influenza season.
Keep in mind that even in December and January it’s not too late to vaccinate. Workers who were unable to get vaccinated during our event should still consider getting their influenza vaccination. They can contact our pharmacy or speak to their physicians about their options.
If possible, we would appreciate any feedback you can provide that we can incorporate into next year’s program.
Again, thanks. We appreciate the opportunity to provide a valuable service to your staff and to the community.
Sincerely,
[Your Name]
SAMPLE SHORT ARTICLE FOR EMPLOYERS
Influenza Vaccinations Available
If you’ve ever had influenza, you know how miserable it can make you feel. Symptoms include fever, aches, chills, and fatigue. In severe cases, influenza can lead to hospitalization. Influenza and its complications can even be fatal.1
The best thing you can do to protect yourself, your family, and the people around you is to get vaccinated against influenza.
[If company is sponsoring a workplace immunization event:]
And now it’s easier than ever to get your influenza vaccination. Pharmacists from [name of local pharmacy] will be coming to our offices to administer the vaccine in [location of event] on [dates] from [start time] to [end time]. To make an appointment, [insert instructions for making appointments].
[If company is announcing a pharmacy immunization event:]