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.