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REPORTING FORMS
How to Report
What to Report
What to Include
Company Report
Confidentiality information for reporters
PATIENT
Patient name or initials
Patient NHI
Patient Address
Patient Address 2
Patient Address 3
Patient Phone
Patient Sex
Female
Male
Patient DOB
Patient age at onset of Event
Patient Ethnicity
European
Māori
Pasifika
Asian
Indian
Other
Patient Ethnicity Other Specify
REPORTER
Reporter Name
Reporter Occupation
Doctor
Nurse
Pharmacist
Other
Reporter Institution
Reporter Address
Reporter Address 2
Reporter Address 3
Reporter Phone
Reporter Email
Date
Health Facility (or vaccination centre) name:
Adverse Events
Local reaction
If yes, size cm:
Beyond nearest joint
Persisting > 3 Days
Abscess
Lymphadenopathy
Fever >38°
Fever >40°
Myalgia
(Severe
)
Arthalgia
(Severe
)
Headache
(Severe
)
Diarrhoea
(Severe
)
Nausea
(Severe
)
Vomiting
(Severe
)
Paraesthesia/Numbness
Rash
(Severe
)
Pruritis/Itching
(Severe
)
Throat tight
(Severe
)
Wheeze
(Severe
)
Angioedema
Urticaria/Hives
Neurological event
Thrombocytopenia
Vasovagal/Syncope
Other (specify)
Anaphylaxis
(if yes
Tryptase taken
Positive)
Seizures
(if yes
Febrile
Afebrile
Unknown)
Date and time AEFI started
Date:
Time:
Describe AEFI (signs and symptoms)
Serious
Serious
Death
Life Threatening
Disability
Hospitalisation
Congenital anomaly
Other
Outcome
Recovering
Recovered
Recovering with sequelae
Not recovered
Unknown
Died
Died
Autopsy done
Yes
No
Unknown
Date of Death
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). Use additional sheet if needed.
Pregnant
(Yes? Gestation/LMP
)
Lactating
Submit
