Assessment of Influenza Vaccine Shortage for Patients in Dialysis Centers 2004-2005 Influenza Season

---

DIALYSIS CENTER INFORMATION
1.	6-digit Medicare Provider Number:
2.	Facility Name:
3.	Name of person completing this survey:
4.	Phone number of person completing this survey:	-  -

 

VACCINE SUPPLY INFORMATION
5.	Did your dialysis center order influenza vaccine for the 2004-05 influenza season? If no, survey complete. Thanks! If yes, please continue to Question #6.	Yes       No
6.	Provide the number of vaccine doses ordered and received for patients from each of the following suppliers to date:    Supplier # Doses ordered # Doses received Chiron Aventis Pasteur Other, specify:
7.	Which of the following statements accurately describes the current status of vaccine supply at your center? The center has no vaccine. The center is short of vaccine and currently has no arrangements to receive further vaccine. The center is short of vaccine, but has made arrangements to receive some of the doses needed. The center is short of vaccine, but has made arrangements to receive the full amount of doses needed. The center has no shortage of vaccine.