REPORT OF AN ADVERSE EVENT FOLLOWING IMMUNISATION (AEFI)

ACT CASE NO: ______

1. PERSON WHO EXPERIENCED THE ADVERSE EVENT

Name______DOB___/___/__

Address______Postcode______

If a child, Parent/Guardian Name______Phone______

2. PAST MEDICAL HISTORY

If a child under 5 years - birth weight ______Gestational age (length of pregnancy)______

Any known allergies?______

Any other medical conditions?______

Does the person take any routine medications?______

Any prior adverse events following immunisation? NO/YES: If Yes, provide details______

______

General Practitioner______Phone______

3.  VACCINES GIVEN ON THE DAY OF THE ADVERSE EVENT

Vaccine Provider Name/location______Phone______

Vaccine
Type / Dose No / Date & Time
Administered / Manufacturer / Batch No / Route/Site/Side (left or right)
Were any other vaccines given within 4 weeks prior to the adverse event? NO/YES: If Yes, specify details:

______

4. WHAT WAS THE NATURE OF THE ADVERSE EVENT?

Was the person ill before the vaccine was given? No/Yes If Yes, provide details______

______

Date and time reaction occurred______

Describe the adverse event______

______

______

______

______

How long did the event last? ______Recovery complete?______

Was paracetamol given? NO/YES Was any other treatment required? NO/YES

If yes, describe what was required and who advised or provided the treatment______

______

______

5. DETAILS OF PERSON REPORTING THIS ADVERSE EVENT

Name ______Phone______Date: ___ /____ /____

Address______Report taken by: ______

Health Protection Service will contact the immunisation provider, parent, or person who experienced the adverse event to clarify details regarding the immunisation and the following events.

On completion, please fax this form to 6205 1738, or mail to:

Health Protection Service, Locked Bag 5005, Weston Creek, ACT 2611. Form Revised June 2011

(OFFICE USE ONLY)

Date Report Received: ___ /___ /___

FOLLOW UP DETAILS

Initial follow up: No/Yes Person with whom follow up made______

Did the patient make a complete recovery? No/Yes

Comments: ______

______

______

______

______

______

______Follow up by______Date:____/____/_____

Second follow up: No/Yes Person with whom follow up made______

Did the patient make a complete recovery? No/Yes

Comments: ______

______

______

______

______

______Follow up by______Date:____/____/____

Third follow up: No/Yes Person with whom follow up made______

Did the patient make a complete recovery? No/Yes

Comments______

______

______

______Follow up by ______Date: ____/____/____

Form sent to ADRAC ____/____/____ ADRAC

Classification______

Recommendations/comments______

______

______

______

______

______

______date:____/____/_____