COVID-19 REPORTING FORM FOR ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Reporting Form For Adverse Events Following Immunization (AEFI)
This form is to be completed by physicians for any patients who may have experienced an adverse event following immunization.
Reporter Information
Person completing form
Institution:
Designation and Department:
Street address:
Parish:
Postal code:
Phone
Email:
Date patient notified event to health system: (DD/MM/YYYY ie: 18/01/2021)
Day / Month / Year
Time:
Radiobutton

AM PM
Today's date:
Day / Month / Year

Additional Information
First Decision making level to complete:
Investigation needed:

Yes No
If yes, date investigation planned: (DD/MM/YYYY ie: 18/01/2021)
Day / Month / Year
National level to complete:
Date report received at national level: (DD/MM/YYYY ie: 18/01/2021)
Day / Month / Year
AEFI worldwide unique ID :
Comments:

Blank	Vaccine	*Manufacturer	*Date of vaccination (DD/MM/YYYY ie: 18/01/2021)	*Time of vaccination	Dose (1st, 2nd, etc.)	*Batch/Lot number	Expiry date (DD/MM/YYYY ie: 18/01/2021)
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Reporting Form For Adverse Events Following Immunization (AEFI)