VAERS - Report an Adverse Event Step 1

Completion Status

Report an Adverse Event - Patient Information
Instructions | en Español

Patient Information
Reporter Information
Facility Information
Vaccine Information
Additional Information

Click thumbnail to preview the VAERS report

Click to preview VAERS form

Note: Fields marked with an * are essential and should be completed.

Item 1

Patient first name:

Patient last name:

Street address:

City:

State:

County:

Zip code:

Phone:

Email:

Item 2

* Date of birth

( mm/dd/yyyy or mm/yyyy)

Item 3

* Sex:
Male Female Unknown

Item 4

* Date of vaccination

( mm/dd/yyyy or mm/yyyy)

Time:

AM PM

Item 5

* Date adverse event started

( mm/dd/yyyy or mm/yyyy)

Time:

AM PM

Item 6

* Age at vaccination

years

months

Item 7

Today's date:

Item 8

Pregnant at time of vaccination?:
(If yes, describe the event, any pregnancy complications, and estimated due date if known in item 18 )
Yes No Unknown

Item 9

Prescriptions, over-the-counter medications, dietary supplements, or herbal remedies being taken at the time of vaccination:

Item 10

Allergies to medications, food, or other products:

Item 11

Other illnesses at the time of vaccination and up to one month prior:

Item 12

Chronic or long-standing health conditions:

Warning: Knowingly filing a false VAERS report with the intent to mislead the Department of Health and Human Services is a violation of Federal law (18 U.S. Code � 1001) punishable by fine and imprisonment.

Vulnerability Disclosure Policy - HHS.gov

VAERS is co-sponsored by the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), agencies of the U.S. Department of Health and Human Services (HHS).

Completion Status

Report an Adverse Event - Patient Information Instructions | en Español

Item 1

Item 2

Item 3

Item 4

Item 5

Item 6

Item 7

Item 8

Item 9

Item 10

Item 11

Item 12

Report an Adverse Event - Patient Information
Instructions | en Español