Vaccine Adverse Effect Reporting Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastStreet Address *City/Town/Village Name *Phone Number *Email *Date of Birth *Sex *MaleFemaleDate 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? *YesNoUnknownPrescriptions, 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 *AstraZenecaAstraZenecaModernaPfizerDose Number in Series *First DoseFirst DoseSecond DoseDescribe 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)? *YesNoUnknownResult or Outcome of Adverse Event(s): (Check all that apply) *Doctor Office/Clinic VisitEmergency Department VisitHospitalizationProlonged HospitalizationLife Threatening Illness (immediate risk of death)Disability or Permanent DamageHas 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)?YesNoUnknownEthnicity *BlackWhiteHispanicAsianOther/MixedSubmit Share Facebook Twitter Pinterest Linkedin