Department of Health
Communicable Diseases Prevention Unit
Immunisation section
			
Adverse Event Following Immunisation (AEFI) and
 Vaccine Administration Error (VAE)
			        Reporting Form
 Vaccinated Person Details	
 First name: <PtFirstName>	Surname: <PtSurname>	DOB: <PtDoB>	
 Address: <PtStreet>	Suburb: <PtCity>	Postcode: <PtPostcode>	
 Email:  <PtEmail>	Mobile: <PtPhoneMob>	Gender: <PtSex>	
 Indigenous Status: <PtEthnicity>	
 Parent/Guardian Details	
 First Name:	Surname:	
 Email:	 Mobile:	
Person Reporting Details	
 Report Date: <TodaysDate>			
 Relationship to Vaccinated Person	  <Relationship to patient.>		
 First Name: <UsrFirstName>	 Surname:  <UsrSurname>	 Email: <PracEmail>	
 Organisation Name:	 <Practice>	 Phone: <UsrPhone>	
 Consent	
 By submitting this report, you give consent for the CDPU immunisation team to contact any/all the individuals listed in the report (including the immunised person, parent/guardian, provider, and reporter)	
 Immunisation Provider Details	
 Location	 <Location of vaccine provision>	
 Who Provided the vaccine:	 <Who Provided the vaccine>	
 Name:	 <Name of who provided the Vaccine:>  Phone: <UsrPhone>	
 Organisation	 <Practice>	
 Medical History	
Illness at the time of vaccination?	 <Any Illness at the time of vaccination>	
Received any other vaccine in the last 4 weeks?	 <Received any other vaccines in the last 4 weeks?>	
  If yes, please list:	 <If YES, please list>	
Any important pre-existing medical conditions, including severe allergies?	 <Any important pre-existing conditions including severe allergies  (check pre-populated form after answering these questions)>
	
 If yes, please list:	 <Reactions>
<SelectedPMH>	
 Pregnant at the time of vaccination?	 <Pregnant at time of vaccination>	
     Gestation (if known):	   <If yes, Gestation (if known) in weeks>           weeks	

 Vaccines Administered	
 q Tick if you do not know which vaccine was administered, and skip to “Adverse Event Description”	
 Date of Vaccination: <Date of Vaccination>	  Time of Vaccination: <Time of Vaccination 24 Hr clock> 24Hr clock	

 Vaccine Name
	 Dose Number
  (if known)	 Batch Number
  (If known)	 Route of Administration*	 Site*	
 <Vaccine 1 name>	 <Vaccine 1 Dose No. (If Known)>	 <Vaccine 1 Batch No. (If known)>	 <Vaccine 1 Route of administration>	 <Vaccine 1 Site>	
 <Vaccine 2 name>	 <Vaccine 2 Dose No. (If Known)>	<Vaccine 2 Batch No. (If known)>	 <Vaccine 2 Route of administration>	 <Vaccine 2 Site>	
 <Vaccine 3 name>	 <Vaccine 3 Dose No. (If Known)>	 <Vaccine 3 Batch No. (If known)>	 <Vaccine 3 Route of administration>	 <Vaccine 3 Site>	
 <Vaccine 4 name>	 <Vaccine 4 Dose No. (If Known)>	<Vaccine 4 Batch No. (If known)>	 <Vaccine 4 Route of administration>	 <Vaccine 4 Site>	
*IM = Intramuscular, SC = Subcutaneous, ID = Intradermal, LA = Left Arm, RA = Right Arm, LL = Left Leg, RL = Right Leg, 	
 O = Other Site (please specify)  <If Other Site, please specify>	
 Type of Report	
Are you completing this form to report a Vaccine Administration Error (VAE)?                      <Is this report a VAE>
Are you completing this form to report an Adverse Event Following Immunisation (AEFI)?  <Is this report an AEFI>

Please complete the relevant section below	
 Vaccine Administration Error (VAE) Description	
Type of error:  <Type of error>	
Details of event, including factors that contributed to the VAE: (be as descriptive as you can)
<Details of VAE event>
	
 How was this vaccine administration error identified?
<How was this vaccine administration error identified?>	
 Has the vaccine recipient been informed of the error?  <Has the vaccine recipient been informed of the error?>	
 What actions have been taken to prevent an error such as this from occurring in the future?
 <What actions have been taken to prevent an error such as this from occurring in the future?>	

 Adverse Event Following Immunisation (AEFI) Description	
 Onset Date:   <AEFI Onset Date>   Onset Time (if known):  <Onset time (if known) 24hr clock>     24hr clock	
 Time from vaccination to onset of symptoms:   <Time from vaccination to onset of symptoms: (specify in days, hrs, minutes)>	
 Outcome of event: <Outcome of event>	
 Recovery Date (if relevant):  <Recovery Date if Relevant>	
 Details of event: (be as descriptive as you can):
<Details of AEFI event>	

 Treatment Details	
 Treatment Type	  <Treatment Type>	
Hospital Admission	 <Hospital Admission>  Number of days admitted: <If YES, No of days admitted> Date of Discharge: <If YES, date of discharge>	
Treatment Received	 <Treatment Received>	
Organisation Name	 <Organisation providing treatment>	

 *Once completed please email this form to: tas.aefi@health.tas.gov.au	
The information collected in this report will be reviewed by staff in Public Health Services (Tasmanian Department of Health) to provide advice for immunisation providers and consumers reporting AEFI. To assist in post-market safety monitoring of vaccines, all reports of AEFI are shared with the Therapeutic Goods Administration (TGA) for assessment.	

<NB:>