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: <<Patient Demographics:First Name>>	Surname: <<Patient Demographics:Surname>>	DOB: <<Patient Demographics:DOB>>	
 Address: <<Patient Demographics:Address>>	Suburb: <<Patient Demographics:City>>	Postcode: <<Patient Demographics:Postcode>>	
 Email:  <<Patient Demographics:E-mail>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	Gender: <<Patient Demographics:Sex at Birth>>	
 Indigenous Status: 	
 Parent/Guardian Details	
 First Name:	Surname:	
 Email:	 Mobile:	
Person Reporting Details	
 Report Date: <<Miscellaneous:Date (short)>>			
 Relationship to Vaccinated Person	  q Doctor    q Nurse 		
Full Name: 	 <<Miscellaneous:Current User>>	 Email: <<Practice/Location:E-mail>>	
 Organisation Name:	 <<Practice/Location:Name>>	 Phone: <<Practice/Location:Phone>>	
 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	  General Practice	
 Who Provided the vaccine:	 q Doctor    q Nurse 	
 Name:	                                                        Phone: 	
 Organisation	 <<Practice/Location:Name>>	
 Medical History	
Illness at the time of vaccination?	  q Yes    q No   q Unknown	
Received any other vaccine in the last 4 weeks?	  q Yes    q No   q Unknown	
  If yes, please list:	 	
Any important pre-existing medical conditions, including severe allergies?	  q Yes    q No   q Unknown	
 If yes, please list:	 <<Clinical Details:Allergies/Adverse Reactions>>
	
 Pregnant at the time of vaccination?	 q Yes    q No   q N/A  q Unknown	
     Gestation (if known):	                                         weeks	

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

 Vaccine Name
	 Dose Number
  (if known)	 Batch Number
  (If known)	 Route of Administration*	 Site**	

 	 	 	 	 	
 	 		 	 	
*Route of Administration:  IM = Intramuscular, SC = Subcutaneous, ID = Intradermal, O = Oral 
** Site: LA = Left Arm, RA = Right Arm, LL = Left Leg, RL = Right Leg,  O =Other	
 O = Other Site (please specify)  	
 Type of Report	
Are you completing this form to report a Vaccine Administration Error (VAE)?                          q Yes    q No
Are you completing this form to report an Adverse Event Following Immunisation (AEFI)?     q Yes    q No
Please complete the relevant section below	
 Vaccine Administration Error (VAE) Description	
Type of error:  

    q incomplete dose administered                            q multiple/repeat dose               q administration route error
 q administration after incorrect storage/handling    q expired vaccine administered   q unapproved age group
 q SIRVA                                                               q diluent only administered         q incorrect dose interval
 q Pther (please describe in next section)	
Details of event, including factors that contributed to the VAE: (be as descriptive as you can)

 How was this vaccine administration error identified?

 Has the vaccine recipient been informed of the error?  q Yes    q No	
 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:                       Onset Time (if known):      24hr clock	
 Time from vaccination to onset of symptoms:   	
 Outcome of event:  q Recovered    q Ongoing   q Recovered with complications  q Fatal   q Unknown	
 Recovery Date (if relevant):  	
 Details of event: (be as descriptive as you can):

	

 Treatment Details	
 Treatment Type	  q Self (Did not seek medical assistance)    q Helpline   q Nurse    q GP
  q Hospital Emergency   q Specialist Outpatient Clinic    q Allied Health
  q Unknown     q N/A	
Hospital Admission	   q Hospital Admission     Number of days admitted:          Date of Discharge: 	
Treatment Received	 

	
Organisation Name	 	

 *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.	

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