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 - Download the Writable PDF Form

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.
  • 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 - Upload the Writable PDF Form

Instructions for Uploading the Writable PDF Form

  • 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.
  • 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.

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