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Report Adverse Event Online

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.

Step 1 of 5: Person Reporting Event

Form Completed By: [Help]
Information Kept Confidential [Help]

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04/16/2014
Have You Reported This Adverse Event Previously? (Box 20) [Help]
Only for Reports Submitted by State Health Coordinator or Immunization Project
(mm/dd/yyyy)