2023 MIPS IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff

Activity ID


Activity Weighting


Subcategory Name

Emergency Response And Preparedness

Activity Description

Demonstrate that the MIPS eligible clinician’s practice has maintained or achieved a rate of 100% of office staff staying up to date with COVID vaccines according to the Centers for Disease Control and Prevention (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html). Please note that those who are determined to have a medical contraindication specified by CDC recommendations are excluded from this activity.


Achieve or maintain 100% of practice staff up to date with COVID vaccines.

Suggested Documentation

Evidence supporting that COVID-19 vaccinations are up to date for clinical and non-clinical office staff, according to current CDC guidelines. Include all of the following elements:

1) Documentation approach – Standardized approach to documenting vaccination status for existing and new employees; AND

2) Employee education – Materials emphasizing the importance of COVID-19 vaccination for all staff in a health care setting; AND

3) Documented process for vaccine administration – Written options for staff who require COVID-19 vaccines to receive vaccination at the practice or at other locations.

Examples of Additional Activities that Qualify for Attestation

A practice-wide review indicated that some staff had not received the recommended COVID-19 vaccine doses. The practice educated staff on the importance of COVID-19 vaccination, and provided information on where no-cost vaccines could be obtained.


Register with MDinteractive