Adverse Event Following Immunization

MINISTRY OF HEALTH

National Vaccines and Immunization Program

Adverse Event Following Immunization Reporting Form

Adverse Event Following Immunization
Adverse Event Following Immunization

Tip: Fields marked with * are mandatory

Form ID: new
Important Unique Form ID
Initial (Initial Report: new)

PATIENT DETAILS

-- clear!

If selected, year is mandatory.

--OR--

(static, mass, outreach)

(If patient is a child)

(self or nearest contact)



TYPE OF Adverse Event Following Immunization

:

(Signs & Symptoms)

(including timeline of occurrence)


Suspected Vaccine(s)

(e.g. BCG, DPT-Hib-HeB) (e.g. Dose 1, 2) Route of vaccination
(i.m.,s.c., i.d.)
Manufacturer's Name Expiry date #

Including history of similar reaction or other allergies, concomitant medication/vaccine,concomitant illness, other cases,pregnacy status and other relevant information


clear!
clear!

Action Taken:

(specify)

Specimen collected for investigation (specify type(s) of specimen)


clear!
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# File Text Description
Is the person submitting different from reporter? 
  




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