Patient Information
1. Patient first name:
Patient last name:
Address:
VAERS - Report an Adverse Event Confirmation.
City:
State:
County:
Zip code:
Phone:
Email:
2. Date of birth:
3. Sex:
Male
Female
Unknown
4. Date of vaccination:
Time:
AM
PM
5. Date adverse event started
VAERS - Report an Adverse Event Confirmation.
Time:
AM
PM
6. Age at vaccination:
Yrs
Mos
7. Today's date:
8. Pregnant at time of vaccination?:
Yes
No
Unknown
9. Prescriptions, over-the-counter medications taken:
null
10. Allergies to medications, food, or other products:
null
11. Other illnesses at the time of vaccination and up to one month prior:
null
VAERS - Report an Adverse Event Confirmation.
12. Chronic or long-standing health conditions:
null
Reporter Information
13. Person completing form:
Relation to patient:
Healthcare professional/staff
Parent/Guardian/Caregiver
Patient (yourself)
Other:
Address:
City:
State:
Zip:
VAERS - Report an Adverse Event Confirmation.
Phone:
Email:
14. Best doctor/healthcare professional to contact about the adverse event:
Name:
Phone:
Ext:
Facility Information
15. Facility name:
Fax:
Phone:
Address 1:
VAERS - Report an Adverse Event Confirmation.
Address 2:
City:
State:
Zip:
16. Type of Facility:
Doctor's office, urgent care, or hospital
Pharmacy or store
Workplace clinic
Public health clinic
Nursing home or senior living facility
School or student health clinic
Unknown
Other:
VAERS - Report an Adverse Event Confirmation.
Vaccine Information
17. Enter all vaccines given on the date listed in item 4: (Route is HOW the vaccine was given, Body site is WHERE vaccine was given).
Vaccine
Manufacturer
Lot Number
Route
Body site
Dose number in series
18. Describe the adverse event(s), treatment, and outcome(s), if any:
null
19. Medical tests and laboratory results related to the adverse event(s):
null
20. Has the patient recovered from the adverse event(s)?:
Yes
No
Unknown
VAERS - Report an Adverse Event Confirmation.
21. Result or outcome of adverse event(s):
Doctor or other healthcare professional office/clinic visit
Emergency room/department or urgent care
Hospitalization
Number of days (if known)
Hospital Name
City
State
Prolongation of existing hospitilization
Life threatening illness
Disability or permanent damage
Patient died
Date
Congenital anomaly or birth defect
None of the above
Additional Information
22. Any other vaccines received within one month prior to the date of vaccination (item 4):
Vaccine
Manufacturer
Lot Number
Route
Body site
Dose number in series
Date
VAERS - Report an Adverse Event Confirmation.
23. Has the patient ever had an adverse event following any previous vaccine?:
Yes
No
Unknown
null
24. Patient's race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other:
25. Patient's ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
26. Immunization project report number:
Military/Department of Defense (DoD) related reports
27. Status at the time of vaccination:
Active Duty
Reserve
National Guard
Beneficiary
Other:
VAERS - Report an Adverse Event Confirmation.
28. Vaccinated at Military/DoD site:
Yes
No
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