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National level to complete:

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Date report received at National level: AEFI worldwide unique ID: 
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Comments

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Please click on Complete button to submit the data.

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First Decision making level to complete:

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Investigation needed    \n\t\t\t

If Yes, date investigation planned: 

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Please click on Complete button to submit the data.

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\n\n\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\n
\n\t\t\t

*Reporter's name:

\n\t\t\t
Designation and Department:
Reporting health facility address:
Contact number:
E-mail:
\n \n\n\n\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\n
 Vaccine 1Vaccine 2Vaccine 3Vaccine 4
*Name of the vaccine
Brand Name
Other vaccines(specify)
*Date of vaccination
*Time of vaccination
Dose(1st,2nd,etc.)
*Batch/Lot number
Expiry date
Diluent (if applicable)
*Name of diluent
*Batch/Lot number
Expiry date
Date of reconstitution
Time of reconstitution
\n\n

 

\n\n\n\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\n\t\n
*Adverse event(s)
\n\t\t\t \n\t\t\t

Severe local reaction

\n\n\t\t\t

3 days\" value=\"[ AEFI - Severe local reaction > 3 days ]\"/> >3 days 

\n\n\t\t\t

 Beyond nearest joint

\n\t\t\t Seizures              
\n\t\t\t Abscess
\n\t\t\t Sepsis
\n\t\t\t Encephalopathy
\n\t\t\t Toxic shock syndrome
\n\t\t\t Thrombocytopenia
\n\t\t\t Anaphylaxis
\n\t\t\t Fever (> 38°C)\n\t\t\t

 

\n\n\t\t\t

Other

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Headache  Irritability Sore throat
Joint pain Abdominal Pain Cough 
Nausea Diarrhoea Fatigue
Vomiting Injection site soreness Injection site tenderness
Skin rash Itching Muscle pain
Persistent crying Poor breast feeding  Loss of apetite
Chills  Fainting  Mild fever
Tiredness  Nasal congestion  Lymph node enlargement
Dizziness Drowsiness 
\n\n\t\t\t

Other (Specify) 

\n\t\t\t		\n\t\t\t

Date AEFI Started:  
\n\t\t\t
\n\t\t\tTime  
\n\t\t\t
\n\t\t\tDescribe AEFI (Signs and Symptoms):

\n\n\t\t\t

  

\n\t\t\t
\n\n\n\t\n\t\t\n\t\t\t\n\t\t\n\t\n
\n\t\t\t

 Serious event reported?

\n\n\t\t\t

If yes - Death     Life threatening     Persistant or significant disability    Hospitalization    Congenital anomaly    

\n\n\t\t\t

Other important medical event:   
\n\t\t\t
\n\t\t\tOutcome:

\n\n\t\t\t
If died, date of Death: 
\n\n\t\t\t
 
\n\n\t\t\t
Was an Autopsy requested? 
\n\n\t\t\t
 
\n\t\t\t
\n\n\n\t\n\t\t\n\t\t\t\n\t\t\n\t\n
\n\t\t\t

 

\n\n\t\t\t

Past medical history (including history of similar reaction or other allergies), concomitant medication and other relevant information (e.g. other cases).
\n\t\t\t
\n\t\t\t
\n\t\t\t 

\n\t\t\t
\n\n

*Compulsory Field

\n\n

Please click on Complete button to submit the data

\n\n

 

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