S Vaccine Adverse Event Reporting System

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VAERS
Items 2, 4, 5, 6, 17, 18 and 21 are ESSENTIAL and must be completed.
Vaccine Adverse Event Reporting System
Patient identity kept confidential. Use Continuation Page (page 2) if necessary.
INFORMATION ABOUT THE PATIENT WHO RECEIVED THE VACCINE
Use Continuation Page (page 2) for nos. 9-12, if necessary
1. Patient name:
9. Prescriptions, over-the-counter medications, dietary supplements or
(First)
(Last)
herbal remedies being taken at time of vaccination:
Street address:
City:
State:
County:
ZIP code:
Tele: (
)
Email:
10. Allergies to medications, food, or other products:
(Explain)
2. Date of birth:
(mm/dd/yyyy)
/
/
3. Sex:
�
Male
�
Female
�
Unknown
/
/
�AM
4. Date and time of vaccination:
11. Other illness at the time of vaccination and up to one month prior:
(mm/dd/yyyy)
Time:
�PM
�AM
5. Date and time adverse event started:
/
/
(mm/dd/yyyy)
Time:
�PM
6. Age at vaccination:
Years
Months 7. Today’s date:
/
/
12. Chronic or long-standing health conditions:
(mm/dd/yyyy)
8. Report is about vaccine administered to a pregnant woman:
�
No or unknown
�
Yes
(If Yes, describe pregnancy history, estimated date of delivery, birth weight if available, and the event in no. 18)
INFORMATION ABOUT THE PERSON COMPLETING THIS FORM
INFORMATION ABOUT FACILITY WHERE VACCINE WAS GIVEN
13. Form completed by:
15. Facility/clinic name:
16. Type of facility:
(Name)
�
Doctor’s office or hospital
Relation to patient:
�
Healthcare professional/staff
�
Patient
(yourself)
Fax: (
)
�
Pharmacy or drug store
�
Parent/guardian/caregiver
�
Other:
Street address:
� Check if same as no. 13
�
Workplace clinic
Street address:
� Check if same as no. 1
�
Public health clinic
City:
State:
ZIP code:
Nursing home or senior living facility
City:
�
Tele: (
)
Email:
State:
ZIP code:
�
School/student health clinic
14. Best doctor/healthcare
Name:
Tele: (
)
�
Other:
professional to contact
Tele: (
)
Ext:
about the patient:
�
Unknown
Email:
WHAT VACCINES WERE GIVEN? WHAT HAPPENED TO THE PATIENT?
Use Continuation Page (page 2) for nos. 17-19, if necessary
17. Enter all vaccines given on date listed in no. 4:
(Route is HOW vaccine was given, body site is WHERE vaccine was given)
Dose no.
Vaccine
Manufacturer
Lot number
Route
Body site
in series
(type and brand name)
18. Describe event(s), treatment and outcome(s), if any:
21. Result or outcome of event:
(symptoms, signs, time course, etc.,)
(Check all that apply)
�
Doctor or other healthcare professional office/clinic visit
�
Emergency room or emergency department visit
Hospitalization: Number of days
�
(if known)
Hospital name:
City:
State:
�
Prolongation of existing hospitalization
(Vaccine received during existing hospitalization)
Life threatening illness
�
19. Medical tests and laboratory results related to event(s):
�
Disability or permanent damage
(Include dates)
�
Patient died: Date of death
/
/
(mm/dd/yyyy)
Congenital anomaly or birth defect
�
20. Patient has recovered from event:
�
Yes
�
No
�
Unknown
None of the above
�
Use Continuation Page (page 2) for nos. 22-23, if necessary
ADDITIONAL INFORMATION
22. Any other vaccines received within one month prior to the date listed in no. 4:
Dose no.
(Route is HOW vaccine was given, body site is WHERE vaccine was given)
Vaccine
Manufacturer
Lot number
Route
Body site
in series
(type and brand name)
23. Has the patient ever had an adverse event following any previous vaccine:
(If yes, describe and include patient age, vaccination dates, and vaccine type and brand name)
�
No or unknown
�
Yes
24. Patient’s race:
�
American Indian or Alaska Native
�
Asian
�
Black or African American
�
Native Hawaiian or Other Pacific Islander
(Check all that apply)
�
White
�
Unknown
�
Other:
25. Patient’s ethnicity
Unknown 26. Immuniz. proj. report no.:
�
Hispanic or Latino
�
Not Hispanic or Latino
�
(Health Dept use only)
FOR U.S. MILITARY/DEPT OF DEFENSE (DoD) RELATED REPORTS (Complete only if applicable)
28. Vaccinated at Military/DoD site:
�
Yes
�
No
27. Status at time of vaccination:
�
Active duty
�
Reserve
�
National Guard
�
Other:
Use Continuation Page (page 2) if necessary.
FORM FDA VAERS-2.0 (1/15)
Page 1 of 2

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