Form Vaers-1 - Patient Identity Kept Confidential
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VACCINE ADVERSE EVENT REPORTING SYSTEM
For CDC/FDA Use Only
24 Hour Toll-Free Information 1-800-822-7967
VAERS Number
P.O. Box 1100, Rockville, MD 20849-1100
Date Received
PATIENT IDENTITY KEPT CONFIDENTIAL
Form completed by (Name):
Vaccine administered by (Name):
Patient Name:
First
Last
M.I.
Relation
Responsible
Vaccine Provider
Patient/Parent
to Patient
Physician
Manufacturer
Other
Address
(if different from patient or provider)
Address
Facility Name/Address
State
State
City
Zip
City
Zip
City
State
Zip
Telephone no. (____) ______________________
Telephone no. (____) ______________________
Telephone no. (____) ______________________
4. Patient age
5. Sex
3. Date of birth
6. Date form completed
1. State
2. County where administered
M
F
mm
dd
yy
mm
dd
yy
8. Check all appropriate:
7.
Describe adverse events(s) (symptoms, signs, time course) and treatment, if any
Patient died
(date
)
mm
dd
yy
Life threatening illness
Required emergency room/doctor visit
Required hospitalization (________days)
Resulted in prolongation of hospitalization
Resulted in permanent disability
None of the above
11. Adverse event onset
Date of vaccination
10.
9. Patient recovered
YES
NO
UNKNOWN
12. Relevant diagnostic tests/laboratory data
mm
dd
yy
mm
dd
yy
AM
AM
Time ____________ PM
Time ____________ PM
13. Enter all vaccines given on date listed in no. 10
No. Previous
Route/Site
Doses
Lot number
Vaccine (type)
Manufacturer
a.
b.
c.
d.
14. Any other vaccinations within 4 weeks prior to the date listed in no. 10
Date
No. Previous
given
doses
Lot number
Route/Site
Vaccine (type)
Manufacturer
a.
b.
16. Vaccine purchased with:
17. Other medications
15. Vaccinated at:
Private funds
Military funds
Military clinic/hospital
Private doctor's office/hospital
Other/unknown
Public funds
Other/unknown
Public health clinic/hospital
18. Illness at time of vaccination (specify)
19. Pre-existing physician-diagnosed allergies, birth defects, medical conditions (specify)
Only for children 5 and under
20. Have you reported
No
To health department
this adverse event
23. No. of brothers and sisters
22. Birth weight
To manufacturer
previously?
To doctor
__________ lb. _________ oz.
Only for reports submitted by manufacturer/immunization project
21. Adverse event following prior vaccination (check all applicable, specify)
Onset
Type
Adverse
Dose no.
25. Date received by mfr./imm.proj.
24. Mfr./imm. proj. report no.
Age
Vaccine
in series
Event
In patient
26. 15 day report?
27. Report type
In brother
or sister
Follow-Up
Initial
Yes
No
Health care providers and manufacturers are required by law (42 USC 300aa-25) to report reactions to vaccines listed in the Table of Reportable Events Following Immunization.
Reports for reactions to other vaccines are voluntary except when required as a condition of immunization grant awards.
Form VAERS-1(
)
FDA
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