WEBSITE: www.enivd.de
E-MAIL: Domingo-CarrascoC@rki.de
Phone: ++49 1711605757
For internal Use Only
YELLOW FEVER VACCINE ADVERSE EVENT
REPORTING SYSTEM
Registration Number:
Robert Koch Institut, Nordufer 20, 13353 Berlin, Germany
Date Received:
/
/
PATIENT IDENTITY KEPT CONFIDENTIAL
Vaccine administered by (Name):
Patient Name:
Form completed by (Name):
Relation
Vaccine Provider
Patient/Parent
to Patient
Manufacturer
Other
Address (if different from patient or provider)
Responsible Physician:
Address:
Facility Name/Address
City Zip code:
Telephone no: (0)
Fax no: (0)
City Zip code:
Telephone no: (0)
Fax no: (0)
1. County where administered:
2. Date of birth:
Telephone no: (0)
Fax no: (
)
/
3. Patient age:
/
5. Date form completed
4. Sex
M
dd / mm / yyyy
/
F
/
dd / mm /yy yy
7. Check all appropriate:
Patient died (date)
6. Describe adverse events(s) (symptoms, signs, time course) and treatment, if any
/
/
Life threatening illness dd / mm /yy yy
Required emergency room/doctor visit
Required hospitalization (
days)
Resulted in prolongation of hospitalization
Resulted in permanent disability
None of the above
8. Patient recovered
YES
NO
9. Date of vaccination
UNKNOWN
/
11. Relevant diagnostic tests / laboratory data:
10. Adverse event onset
/
/
/
dd / mm/ yy yy
dd / mm / yyyy
Time:
Time:
_____
12. Enter all vaccines given on date listed in no. 9
Vaccine (type)
Manufacturer
Lot number
Route/Site
No. previous doses
a.
b.
c.
d.
13. Any other vaccinations within 4 weeks prior to the date listed in no. 9
Vaccine (type)
Manufacturer
Lot number
Route/Site
No. previous doses
Date given
a.
b.
Private doctor’s office / hospital
14. Vaccinated at:
Public health clinic / hospital
Military clinic / hospital
other / unknown
15. Illness at time of vaccination (specify)
16. Preexisting physician -diagnosed allergies, birth defects, medical conditions (specify
17. Have you reported this
adverse event previously?
No
To public health authorities
To manufacturer
Only for children 5 and under
19. Adverse event following prior vaccination (check all applicable, specify
in patient
in brothers
or sisters
Adverse
Event
Onset age
Type
Vaccine
Doses no.
In series
18. Birth weight
kg
Only for reports submitted by manufacturer/ immunization project
20. Mfr.imm.proj.report no
21. Date received by mfr. /imm.
Proj.
22. 15 day report
23 Report type
Health care providers and manufacturers are required by law to report reactions to vaccines list the Table of Reportable Events Following Immunization.
Reports for reactions to other vaccines are voluntary excepted when required as a condition of immunization grant awards.