PvERS: the Pharmacovigilance Electronic Reporting System: Aefis

Initial Report ID: new

MINISTRY OF HEALTH

National Vaccines and Immunization Program

Adverse Event Following Immunization Reporting Form

Tip: Fields marked with * are mandatory

INSTITUTION NAME *

Form ID: new

Important Unique Form ID

REPORT TYPE:

Initial (Initial Report: new)

INSTITUTION CODE

COUNTY *

SUB-COUNTY *

PATIENT DETAILS

PATIENT'S NAME *

IP/OP NO.

DATE OF BIRTH *

-- clear!

If selected, year is mandatory.

--OR--

Age in months

COUNTY

VACCINATION CENTRE

TYPE OF VACCINATION SERVICE *

(static, mass, outreach)

NAME OF GUARDIAN

(If patient is a child)

ADDRESS

PHONE NUMBER

(self or nearest contact)

VILLAGE

WARD

GENDER *

MaleFemaleUnknown clear!

PREGNANCY STATUS

Not ApplicableNot pregnant

1st Trimester2nd Trimester3rd Trimester clear!

COUNTY OF VACCINATION CENTRE

SUB-COUNTY

TYPE OF Adverse Event Following Immunization

Suspected Vaccine(s)

Details of Vaccines									Details of Diluents
Name of Vaccine *(e.g. BCG, DPT-Hib-HeB)		Dose No.(e.g. Dose 1, 2)	Date & Time vaccinated * (dd-mm-yyyy 24Hr:Min)	Route of vaccination (i.m.,s.c., i.d.)	Site of vaccination	Batch/Lot number *	Manufacturer's Name *	Expiry date	Batch/ Lot Number *	Manufacturer's Name	Expiry date	#

Past medical history

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

SERIOUS *

YesNo clear!

If Yes

DeathLife threateningPersistent or significant disabilityHospitalization or prolongation of existing hospitalizationCongenital anomalyOther important medical event clear!

Action Taken:

Treatment given

(specify)

Specimen collected

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

Adverse Event Following Immunization Outcome:*

Recovered/ResolvedRecovering/ResolvingNot recovered/Not resolved/OngoingRecovered/Resolved with sequelaeFatalUnknown clear!

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#	File	Text Description

Name of Person Reporting *

E-MAIL ADDRESS *

DESIGNATION *

PHONE NO. *

Date *

Is the person submitting different from reporter?

Yes No

Name *