Reporting And Data

MBQIP - HCP/IMM-3: Influenza Vaccination Among Healthcare Personnel

Latest Update: August 11, 2020

Reporting Information

(Note: Formerly OP-27) Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Patient Safety/Inpatient domain, CAHs must report on the influenza vaccination data for HCP physically working in the inpatient and outpatient hospital units for at least one working day between October 1 through March 31, regardless of clinical responsibility or patient contact. This includes all influenza vaccinations administered during the influenza season at the facility or elsewhere, influenza vaccine declinations, and determinations of a medical contraindication to influenza vaccination. Data should be reported separately for employees, licensed independent practitioners, and adult students/trainees and volunteers.

Responsible Party

Who Must Report?

Critical Access Hospitals (CAHs)


When Do I Report?

Annually - May 15


How Do I Report?

Contact Information

Becky Bayley, MBA
Director of Strategic Initiatives

Nevada Rural Hospital Partners
4600 Kietzke Lane, Suite I-209
Reno, NV 89502

Phone: (775) 827-4770


Laima Etchegoyhen, MPH
Outreach and Technical Assistance Coordinator
Nevada Flex Program Coordinator

Office of Statewide Initiatives
University of Nevada, Reno School of Medicine
604 West Moana Lane, MS 3150
Reno, Nevada 89509

work-phone: 775-682-8471
cell-phone: 775-338-9841

website: https://med.unr.edu/statewide


Why Should I Report?

Potential loss of grant funding for not meeting eligibility requirements.

Publicly Displayed

Link to the website/ranking/grading/etc. where the data is published

Results displayed on Hospital Compare and affect the overall star rating for those facilities with large enough volume.


The legal mandate requiring reporting

Health Resources and Services Administration’s (HRSA) Medicare Beneficiary Quality Improvement Program (MBQIP) Memorandum of Understanding (MOU)

Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.