Adverse Event Following Immunisation (AEFI)
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Published: 01 April 2021
Description of elements in the AEFI reporting form
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Patient Details
Patient Name
Patient’s full Address
Telephone
Sex
M
F
Pregnant
Lactating
Date of birth
OR Age at onset
OR Age Group at onset
<1 Year
1 to 5 Years
>5 to 10 Years
Reporter's Details
Reporter’s Name
Institution
Designation & Department
Address
Telephone & E-mail
Date patient notified event to health system
Today’s date
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Health facility (place or vaccination centre) name & address
Name of vaccine (Generic)
Brand name incl name of manufacture
Date of vaccination
Time of vaccination
Dose (1st, 2nd, etc.)
Batch /Lot number
Expiry date
Batch /Lot number
Expiry date
Date and time of reconstitution
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Severe local reaction
>3 days
beyond nearest joint
Seizures
febrile
afebrile
Abscess
Sepsis
Encephalopathy
Toxic shock syndrome
Thrombocytopenia
Anaphylaxis
Fever ≥38°C
Other (specify)
Date AEFI started
Time
Describe AEFI (Signs & Symptoms)
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Serious: Yes / No
Yes
No
If Yes
Death
Life threatening
Persistent or significant disability
Hospitalization
Congenital anomaly
Other important medical event (specify)
Outcome
Recovering
Recovered
Recovered with sequelae
Not Recovered
Unknown
Died
If Died, date of death
Autopsy done
Yes
No
Unknown
Past medical history (including history of similar reaction or other allergies), concomitant medication and other relevant information (e.g. other cases). Use additional sheets if needed:
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Investigation needed
Yes
No
If Yes, date investigation planned
Date report received at National level
AEFI worldwide unique ID
Comments
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