Click here to report an Adverse Event
Adverse Event reporting form:
1. PATIENT INFORMATION

Sex  

2. ADVERSE REACTION(S) Describe the reaction(s) symptoms

Outcome  *

Tick all that apply and describe if necessary.

Do you consider the reaction(s) to be serious?  *

Risk factors present:  *

3. SUSPECTED PRODUCT(s) DETAILS  *
4. OTHER MEDICINES TAKEN AT TIME OF REACTION WITH THERAPY DATES  *

(If yes, provide additional relevant information (Name, prescribed for, batch, dosage, treatment dates, etc.)

5. PAST MEDICAL HISTORY  *

(Tick all that apply and describe if necessary)

6. PRESENCE OF ALLERGIES  *

Allergies to  *

7. ANY SUSPECTED REACTIONS TO VACCINES OF EXPANDED PROGRAM ON IMMUNIZATION (EPI)  *
8. ACTION TAKEN, AND TREATMENT GIVEN  *

Action taken:  *

Further Action Taken:  *

9. FIRST DECISION MAKING (For Healthcare Professionals)  *

Investigation needed:  *

10. REPORTER’S INFORMATION

Who is reporting?  *

Select files to upload:

I hereby declare that the information provided is true and correct.

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