Completion Status

Report an Adverse Event - Patient Information

  • Patient Information
  • Reporter Information
  • Facility Information
  • Vaccine Information
  • Additional Information

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

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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.