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Instructions for Completing the VAERS Paper Form

en Español

General

  • Use a separate form for each patient. Complete the form to the best of your ability. Items 3, 4, 7, 8, 10, 11, and 13 are considered essential and should be completed whenever possible. Parents or guardians may need to contact the facility where the vaccine was given for some information (such as manufacturer, lot number, or laboratory data).
  • Information identifying the person who received the vaccine or that person's legal representative is not available to the public.
  • 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.

 Health Care Providers

  • Refer to the VAERS Table of Reportable Events Following Vaccination, which describes all adverse events that health care providers are required to report by law.
  • Health care providers treating a patient for a suspected adverse event should provide information about the adverse event to the vaccine administrator so that he or she may complete a VAERS form.

 Specific Instructions

Form Completed By:

To be used by the person completing the form (e.g. parents/guardians, vaccine distributors, vaccine administrators, the person completing the form on behalf of the patient, or the health professional who administered the vaccine).

Patient Name and Address:

May be used to contact the patient for further information. This information is kept confidential.

Items 1 and 2:

The state and county where the vaccine was given.

Item 4:

Patient age (age at time of vaccination).

Item 7:

Describe the suspected adverse event. Such things as temperature, local and general signs and symptoms, time course, durations of symptoms, diagnosis, treatment and recovery should be noted.

Item 9:

Check "YES" if the patient's health condition is the same as it was prior to the vaccine, "NO" if the patient has not returned to the pre-vaccination state of health, or "UNKNOWN" if the patient's condition is not known.

Items 10 and 11:

Give dates and times as specifically as you can remember. If you do not know the exact time, please indicate "AM" or "PM" if possible. If more than one adverse event occurred, give the onset date and time for the most serious event.

Item 12:

Include "negative" or "normal" results of any relevant tests performed as well as abnormal findings.

Item 13:

List ONLY those vaccines given on the date provided in Item 10.

Item 14:

List any other vaccines that the patient received within 4 weeks prior to the date provided in Item 10.

Item 16:

This section refers to how the person who gave the vaccine purchased it (e.g. source of funds), not to the patient's insurance.

Item 17:

List any prescription or non-prescription medications the patient was taking when the vaccine(s) was given.

Item 18:

List any short-term illnesses the patient had on the date the vaccine(s) was given (e.g. cold, flu, ear infection).

Item 19:

List any pre-existing physician-diagnosed allergies, birth defects, medical conditions (including developmental and/or neurologic disorders) of the patient.

Item 21:

List any suspected adverse events the patient, or the patient's brother or sisters, may have had to previous vaccinations. If more than one brother or sister, or if the patient has reacted to more than one prior vaccine, use additional pages to explain completely. For the onset age of a patient, provide the age in months if less than two years old.

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