VigiCarib Vaccine Reporting Form

VIGICARIB Reporting Form for Adverse Events Following Immunization (AEFI)
This form is intended for health professionals (e.g. doctors, nurses, pharmacists) in CARPHA Member States. Completion of this form is voluntary. If the event being reported has not been medically confirmed, the reporter is advised to seek medical care or assistance from a health professional. The report will be considered as 'preliminary' or 'unconfirmed', and it will be sent to the ministry of health for verification, as per national policies, procedures and criteria. CARPHA is not responsible for case follow-up at the local level.

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Today's Date

Month Day Year
Date
Is this report for a COVID-19 vaccine? *

Yes No
Patient name or Initials *
Please enter the name or initials of the person who experienced the adverse event
Patient Sex
Patient Age (when event occurred - include units) *
Age Group
Name of Health facility (or vaccination centre):
Country *
Vaccine Name *
Enter the name of the vaccine as written on the immunization card
Name of Vaccine Manufacturer *
Date of vaccination *

Month Day Year
Date
Dose (e.g. 1st, 2nd, etc)
State if this was the first or second dose given
Vaccine Batch / Lot Number *
Please enter the lot or batch number written on the immunization card
Vaccine Expiry Date (mm-dd-yyyy or mm-yyyy)
Diluent Batch / Lot Number or state 'Not Applicable'
If no diluent was required, state 'Not Applicable'
Diluent Expiry Date (mm-dd-yyyy, or mm-yyyy, or skip)
Time of Reconstitution
Describe the adverse event (signs and symptoms) *
Indicate if the event involved any of the following - Select all that apply

Severe local reaction Seizures (without fever) Seizures (with fever) Encephalopathy (brain swelling) Thrombocytopenia / blood clotting Anaphylaxis / Severe allergic reaction Fever above 38 deg. Celcius (measured by thermometer)
If you checked 'Severe local reaction' please check all that apply:

Lasted more than 3 days Extended beyond the nearest joint Unknown
Has this event been medically confirmed? *

Yes No
Date adverse event started *

Month Day Year
Date
Time event started?
Does this event meet criteria for 'Serious' (resulting in hospitalisation, persistent or significant disability, birth defect, or death)? If 'Yes', please identify the category in the next question

Yes No Unknown
If you answered 'Yes' above, please indicate the Seriousness Category
Outcome of Adverse Event
If patient died, please indicate date of death

Month Day Year
Date
Past medical history (including similar reactions or allergies, other medicines, etc.) or additional details if known
Enter as much information as possible based on availability
Reporter Name or Alias *
This information will be shared with the national regulatory authority only for follow-up or investigation.
Your Role
Name of your Organization or Company (for health workers)
For local follow-up and verification, please provide Your Phone Number *

Area Code Phone Number
Your Email
example@example.com
Date event was reported to health system or health professional

Month Day Year
Date stated by initial observer/reporter
AEFI Record Number (for public health officials or QPPVs)
Record number used by national or regional PV centre
Status of Case
Supplemental document (e.g. CIOMS report)

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VIGICARIB Reporting Form for Adverse Events Following Immunization (AEFI)