Vaccine Adverse Effect Reporting - Belizean Rights And Justice Movement

Patient Name *

First

Last

Street Address *

City/Town/Village Name *

Phone Number *

Email *

Date of Birth *

Sex *

Male
Female

Date of Vaccination *

Time of Vaccination *

Date Adverse Event Started *

Time Adverse Event Started *

Age (Year and Months) at Time of Vaccination *

Today's Date *

Pregnant at Time of Vaccination? *

Yes
No
Unknown

Prescriptions, over-the-counter medications, dietary supplements, or herbal remedies being taken at the time of vaccination *

Allergies to medications, food, or other products *

Other illnesses at the time of vaccination and up to one month prior *

Chronic or long-standing health conditions *

Vaccine Facility or Clinic Name *

Vaccine Facility or Clinic Address *

Adverse Effect Description *

COVID-19 Vaccine Manufacturer *

Dose Number in Series *

Describe the adverse event(s), treatment, and outcome(s): (symptoms, signs, time course, etc.) *

Medical tests and laboratory results related to the adverse event(s):(include dates) *

Has the patient recovered from the adverse event(s)? *

Yes
No
Unknown

Result or Outcome of Adverse Event(s): (Check all that apply) *

Has the patient ever had an adverse event following any previous vaccine (If yes,describe adverse event, patient age at vaccination, vaccination dates, vaccine type, and brand name)?

Yes
No
Unknown

Ethnicity *