Confidentiality information for reporters
PATIENT

  



REPORTER

Health Facility (or vaccination centre) name:

Adverse Events
Local reaction
If yes, size cm:

(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
(Severe )
Other (specify)
(if yes Tryptase taken Positive)
(if yes Febrile Afebrile Unknown)
Date: Time:

Serious

Outcome

Died
Autopsy done


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