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    Or Initials: (Pregnant Lactating)

    Uploaded by

    zakirmunawar00

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Or Initials: (Pregnant Lactating)

    Uploaded by

    zakirmunawar00
    10 views2 pages

    Original Title

    4_5877741582995687969-1

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views2 pages

    Or Initials: (Pregnant Lactating)

    Uploaded by

    zakirmunawar00

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Dec 2020

    AEFI reporting id number:


    STANDARD REPORTING FORM FOR ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)
    *Patient name or initials: *Reporter’s Name:
    *Patient’s full Address: Institution:
    Designation &Department:
    Telephone: Address:
    Sex: M F (Pregnant Lactating )

    *Date of birth (DD/MM/YYYY): _ _/_ _/_ _ _ _ Telephone & e-mail:


    OR Age at onset : Years Months Days Date patient notified event to health system (DD/MM/YYYY):
    OR Age Group: 0 < 1 year 1- 5 years > 5 years - 18 years
    _ _/_ _/_ _ _ _
    > 18 years – 60 years > 60 years Today’s date (DD/MM/YYYY): _ _/_ _/_ _ _ _

    Health facility (or vaccination centre) name:

    Vaccine Diluent
    Time of
    Name of *Brand Name Dose *Batch/ Expiry reconsti
    *Date of *Time of Expiry date *Batch/ Lot
    vaccine incl. Name of (1st, 2nd, Lot date tution
    vaccination vaccination number
    (Generic) Manufacturer etc.) number

    *Adverse event (s): Describe AEFI (Signs and symptoms):


    Severe local reaction >3 days beyond nearest joint
    Seizures febrile afebrile
    Abscess
    Sepsis
    Encephalopathy
    Toxic shock syndrome
    Thrombocytopenia
    Anaphylaxis
    Fever≥38°C
    Other (specify)................................
    Date & Time AEFI started (DD/MM/YYYY):
    __ __ / __ __ / __ __ __ __ Hr Min

    *Serious: Yes / No ; ➔ If Yes Death Life threatening Disability Hospitalization Congenital anomaly Other
    important medical event (Specify________________________________________________ )

    *Outcome: Recovering Recovered Recovered with sequelae Not Recovered Unknown


    Died If died, date of death (DD/MM/YYYY): __ __ / __ __ / __ __ __ __ Autopsy done: Yes No Unknown

    Past medical history (including history of similar reaction or other allergies), concomitant medication and dates of administration (exclude
    those used to treat reaction) other relevant information (e.g. other cases). Use additional sheet if needed :

    First Decision making level to complete:


    Investigation needed: Yes No If yes, date investigation planned (DD/MM/YYYY):
    __ __ / __ __ / __ __ __ __
    National level to complete:
    Date report received at national level (DD/MM/YYYY): AEFI worldwide unique ID :
    __ __ / __ __ / __ __ __ __
    Comments:

    *Compulsory field

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