Form Fda Vaers-2.0 - Vaccine Adverse Event Reporting System Page 2

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CONTINUATION PAGE
(Use only if you need more space from the front page).
VAERS
17. Enter all vaccines given on the date listed in item 4 (continued):
Dose no.
in series
Vaccine (type and brand name)
Manufacturer
Lot number
Route
Body site
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
22. Any other vaccines received within one month prior to the date listed in item 4
(continued):
Dose no.
in series
Vaccine (type and brand name)
Manufacturer
Lot number
Route
Body site
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
select
Use the space below to provide any additional information (indicate Item number):
FORM FDA VAERS-2.0 (6/17)

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