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  • Adverse event following immunisation (AEFI) reporting form · Adverse event following immunisation (AEFI) reporting form Author: QLD Health Immunisation Program, Communicable Diseases
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Vaccinated person details Vaccination provider details Surname First name ................................................................................................................. Gender: Male Female Unknown Date of Birth: ............. / ........... / ................. or Age: Year Month Street Address .................................................................................................................. Suburb State Postcode .................................................................................................................. Name of parent/guardian (if relevant) .................................................................................................................. Phone: Home: ................................... Mobile: ......................................... Email: ........................................................................................................ Indigenous status: Is the person of Aboriginal or Torres Strait Islander origin? Aboriginal Torres Strait Islander (TSI) Aboriginal and TSI Not Aboriginal or TSI Not Stated/ Unknown Important medical history: (e.g. requires regular medical follow up.) ...... .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. Allergies ................................................................................................... .................................................................................................................. Was the person ill at the time of vaccination? No Yes – please specify .................................................................. Has the vaccinated person had previous reactions to vaccinations? No Yes – please specify .................................................................. Unknown Surname First name ................................................................................................................. Practice/clinic/provider name: .................................................................................................................. Street Address .................................................................................................................. Suburb State Postcode .................................................................................................................. Phone: Office: ................................... Mobile: ......................................... Email: ........................................................................................................ Fax: ........................................................................................................... Profession: Medical practitioner Registered Nurse Other, please specify ............................................................................ Clinical setting: GP practice Council clinic Aged care facility School vaccination program Hospital Unknown Other, please specify ............................................................................ Address of service where vaccine was administered: As for vaccination provider (above) or Name of practice/clinic/provider .................................................................................................................. Street Address .................................................................................................................. Suburb State Postcode .................................................................................................................. Phone: Office: ................................... Mobile: ......................................... Email: ........................................................................................................ Reporter details (if different from vaccinated person details or vaccination provider details) As per vaccinated person’s details (above) or As per vaccination provider details(above) OR Surname First name Practice Name (if relevant) ........................................................................................................................................................................................................................................ Street Address Suburb State Postcode ........................................................................................................................................................................................................................................ Phone: landline (incl. area code) ........................................................................... Phone: mobile ................................................................................. Email ..................................................................................................................................... Date of report ...................../ ................... / .................. Reporter type: Medical practitioner Registered nurse Vaccinated person Parent/guardian Other, please specify ................................................................................................................................................................................................... If you require further information following an adverse event please contact your local Public Health Unit Consent statement I, the reporter, agree to be contacted for further follow up regarding this adverse event if necessary. Yes No Signature .............................................................................Date ..................... / ......................./ ...................... Please advise the parent/patient that contact details will be used to follow up if information is needed. Adverse Event Following Immunisation Reporting Form Office Use Only Date Report Received: NOCs ID no.: TGA ID no.:

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Page 1: Adverse event following immunisation (AEFI) reporting form · Adverse event following immunisation (AEFI) reporting form Author: QLD Health Immunisation Program, Communicable Diseases

Vaccinated person details Vaccination provider details

Surname Firstname

.................................................................................................................

Gender: Male Female Unknown

DateofBirth:............. /........... /................. orAge: Year Month

StreetAddress

..................................................................................................................

Suburb State Postcode

..................................................................................................................

Nameofparent/guardian(ifrelevant)

..................................................................................................................

Phone:Home:................................... Mobile:.........................................

Email:........................................................................................................

Indigenous status:

IsthepersonofAboriginalorTorresStraitIslanderorigin?

Aboriginal TorresStraitIslander(TSI)

AboriginalandTSI NotAboriginalorTSI

NotStated/Unknown

Important medical history:(e.g.requiresregularmedicalfollowup.)......

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

Allergies...................................................................................................

..................................................................................................................

Wasthepersonillatthetimeofvaccination?

No Yes–pleasespecify..................................................................

Hasthevaccinatedpersonhadpreviousreactionstovaccinations?

No Yes–pleasespecify..................................................................

Unknown

Surname Firstname

.................................................................................................................

Practice/clinic/providername:

..................................................................................................................

StreetAddress

..................................................................................................................

Suburb State Postcode

..................................................................................................................

Phone:Office:................................... Mobile:.........................................

Email:........................................................................................................

Fax:...........................................................................................................

Profession:

Medicalpractitioner RegisteredNurse

Other,pleasespecify............................................................................

Clinical setting:

GPpractice Councilclinic Agedcarefacility

Schoolvaccinationprogram Hospital Unknown

Other,pleasespecify............................................................................

Address of service where vaccine was administered:

Asforvaccinationprovider(above)

or

Nameofpractice/clinic/provider

..................................................................................................................

StreetAddress

..................................................................................................................

Suburb State Postcode

..................................................................................................................

Phone:Office:................................... Mobile:.........................................

Email:........................................................................................................

Reporter details (if different from vaccinated person details or vaccination provider details)

Aspervaccinatedperson’sdetails(above)or Aspervaccinationproviderdetails(above)OR

Surname Firstname PracticeName(ifrelevant)

........................................................................................................................................................................................................................................

StreetAddress Suburb State Postcode

........................................................................................................................................................................................................................................

Phone:landline(incl.areacode)...........................................................................Phone:mobile.................................................................................

Email..................................................................................................................................... Dateofreport...................../................... /..................

Reporter type:

Medicalpractitioner Registerednurse Vaccinatedperson Parent/guardian

Other,pleasespecify...................................................................................................................................................................................................

If you require further information following an adverse event please contact your local Public Health Unit

Consent statement

I,thereporter,agreetobecontactedforfurtherfollowupregardingthisadverseeventifnecessary. Yes No

Signature.............................................................................Date..................... /......................./......................

Please advise the parent/patient that contact details will be used to follow up if information is needed.

Adverse Event Following Immunisation Reporting Form

OfficeUseOnly

DateReportReceived:

NOCsIDno.:

TGAIDno.:

Page 2: Adverse event following immunisation (AEFI) reporting form · Adverse event following immunisation (AEFI) reporting form Author: QLD Health Immunisation Program, Communicable Diseases

Vaccine details

Adverse event detailsOnset of event:Date........... /............ /............ Time.....................................................

Descriptionofevents,includingtimelineofoccurrences(pleaseprovideaseparatepageifneeded):

.........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

Management of event:(tickasmanyasapply)

Nurseassessment Medicalassessment

Hospitalemergencydepartment

Hospitaladmission:numberofdays(ifapplicable)..............................

dateofdischarge........... /.............. /..............

None Unknown Other,pleasespecify....................................

..................................................................................................................

..................................................................................................................

Pleasespecifythetreatment/careprovided(egantibiotics,adrenaline,advice,counselling,etc):

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

Outcome:

Havethesymptomsresolved?

Yes–Bywhatdate/time?

Date.......... /.............../............... Time.................................................

No–Symptomsareongoingasof

Date.......... /.............../............... Time.................................................

Pleasedescribeongoingsymptoms.........................................................

...................................................................................................................

...................................................................................................................

...................................................................................................................

Unknown

Once completed, immediately send the form to:Email:[email protected]:33289434

It is important that Adverse Event Following Immunisation reports are reported promptly.

Office use only - Public Health Unit

Isfollow-upofthepatientrequired? No Yes–Timeframeforfollowup Sameday Nextworkingday Next60days

Details:...........................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................

Signature.................................................................................................. Date............/............. /..............

Privacy statement The Information Privacy Act 2009 sets out the ways in which a health agency can collect personal information for the purpose of reporting Adverse Events Following Immunisation (AEFI). The Public Health Act 2005 requires Queensland Health to record the reporting of AEFI to Queensland Health for inclusion on a state register. If further follow up is required following an adverse event the information stored on the Notifiable and Other Conditions register will be used. Adverse Events Following Immunisation (AEFI) reports collects details such as the vaccinated person’s name, contact information and relevant health information. Details pertaining to the adverse event, important medical history relevant for follow up following the adverse event, details of the provider who administered the vaccine, reporter details and vaccination details are requested and recorded for each AEFI report. Authorised Queensland Health staff may access the information for the purpose of clinical follow up and monitoring. Personal information will not be accessed by or given to any other person or organisation without permission unless permitted or required by law. For information about how Queensland Health protects personal information, or to learn about the right to access your own personal information, please see our website at www.health.qld.gov.au

All reports are provided to the Therapeutic Goods Administration (TGA) to be entered into the TGA’s Australian Adverse Drugs Reactions System (the ADRS). Information about how the TGA uses adverse event information that is reported is available at www.tga.gov.au/safety/problem.htm.

Vaccine (brand name) Dose no. Batch no. Date

givenTime given

Route of administration Injection site

O IM SCID IN U

RA LA URL LL NA

O IM SCID IN U

RA LA URL LL NA

O IM SCID IN U

RA LA URL LL NA

O IM SCID IN U

RA LA URL LL NA

O IM SCID IN U

RA LA URL LL NA


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