Report an Adverse Event with a Writable PDF Form

Warning: This application works best on a desktop or laptop computer. Please continue on a secure computer.

Step 1 - Instructions for Downloading the Writable PDF Form

  • Download the form and save it to your computer
    Right click on the "Download the Writable PDF Form" button below, then select "Save Link As" or "Save Target As" to save the form to your computer. Form last updated on September 2024.
  • Complete the form electronically on your own time
    Use Acrobat 5.0 (or later) to open the file and fill the VAERS Writable PDF Form.
  • Save your completed form
    Use a computer where you can securely save a document that contains protected health information, personal identifiers or other sensitive personal or patient information.
  • Submit to VAERS using the "Upload the Writable PDF Form" button in Step 2

Important: Use a desktop or laptop computer on which you can securely save a document that contains protected health information, personal identifiers or other sensitive personal or patient information.

Download the Writable PDF Form

Step 2 - Instructions for Uploading the Writable PDF Form

  • Verify you are using the latest version of the form, updated September 2024 (available in Step 1 section of this page).
  • Enter your name and email address.
  • Click on the "Browse" button, then navigate to the folder where you have saved the completed Writable PDF form.
  • Select the Writable PDF form to upload.
  • Mark the checkbox to verify you read and understand the above information.
  • Verify that you would like to proceed to upload the file by typing the characters shown in the picture and click "Upload the Writable PDF Form".
  • You will be provided an E-number for your reference on successful submission.

All fields marked with * are required.

Please note:

  • VAERS staff will contact you by email or letter to confirm receipt of this report. If needed, VAERS staff may also contact you to ask for missing information and recovery status. In rare cases, they may contact you by phone. This is the only communication that VAERS staff will have with reporters.
  • VAERS staff will not make a determination as to whether the vaccine caused the adverse event reported. For medical advice, contact your healthcare provider.

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If you need further assistance with reporting to VAERS, please email info@VAERS.org or call 1-800-822-7967.

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).