VigiCarib Vaccine Reporting Form

This form is intended for use by health professionals, representatives of market authorisation holders, and country focal points to submit case reports of adverse events following immunisation (AEFIs) identified in CARPHA Member States. However, since patients or caregivers may want to use this form, they are advised to consult a doctor or pharmacist for assistance.

If there are multiple suspected vaccines, please complete a form for each one, and in the case narrative, you may simply refer to the first form submitted.

Reports from persons outside of the Ministy of Health will be forwarded to the focal points accordingly. Based on the seriousness of the reaction or the threat to public health, the national regulatory authorities will follow up with the reporter as needed. All reports are considered 'preliminary' or 'unconfirmed' until the national authority conducts its verification or investigation of the case. CARPHA is not responsible for case follow-up at the local level.

We understand that you may not have all the details at the time of making the report, but the most important details we need are:

a way to identify the patient (e.g. initials, alias),
the age and sex of patient,
a description of the reaction / event,
the name of the vaccine,
the date they got the vaccine,
the date the reaction or event began
the name and contact for the reporter, and
the country where the person got the vaccine.

Of course, if you have more details, like other medicines taken recently, or if the person has recovered, please include them. Where you do not have the information for a field, you can state 'not available' or skip to the next field.

Caribbean Public Health Agency is committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. Information collected is subject to CARPHA's privacy policy. See the full policy at:https://carpha.org/Privacy.

If you have any questions about this form, you may email us at vigicarib@carpha.org.

Today's Date

DayMonthYear

Is this report for a COVID-19 vaccine?*

YesNo

Patient name or Initials*

Please enter the name or initials of the person who experienced the adverse event

Patient Sex

Patient Age (when event occurred)*

Age units

E.g. months, years

Name of Health facility (or vaccination centre):

Country*

Vaccine Name*

Enter the name of the vaccine as written on the immunization card

Name of Vaccine Manufacturer*

Date of vaccination*

DayMonthYear

Dose (e.g. 1st, 2nd, etc)

State if this was the first or second dose given

Vaccine Batch / Lot Number*

Please enter the lot or batch number written on the immunization card

Vaccine Expiry Date (mm-yyyy, or dd-mm-yyyy)

Diluent Batch / Lot Number

If no diluent was required, state 'Not Applicable'

Diluent Expiry Date (dd-mm-yyyy, or mm-yyyy, or 'N/A')

Time of Reconstitution and Administration (A.M. / P.M. format), if applicable and available

E.g. 8:00 a.m., 2:15 p.m., between 3 and 4 p.m.

Description of the adverse event (signs and symptoms). Include name of diluent given, and other details*

Indicate if the event involved any of the following - Select all that apply

If you checked 'Severe local reaction' please check all that apply:

Lasted more than 3 daysExtended beyond the nearest jointUnknown

Has this event been medically confirmed?*

YesNo

Date adverse event started*

DayMonthYear

Time event started?

E.g. 4:20 p.m.

Does this event meet criteria for 'Serious' (resulting in hospitalisation, persistent or significant disability, birth defect, or death)? If 'Yes', please identify the category in the next question

YesNoUnknown

If you answered 'Yes' above, please indicate the Seriousness Category

Outcome of Adverse Event

If patient died, please indicate date of death

DayMonthYear

Past medical history (including similar reactions or allergies, other medicines, etc.) or additional details if known

Enter as much information as possible based on availability

Reporter Name or Alias*

This information will be shared with the national regulatory authority only for follow-up or investigation.

Your Role

Name of your Organization or Company (for health workers)

For local follow-up and verification, please provide Your Phone Number*

Area CodePhone Number

Your Email

example@example.com

Date event was reported to health system or health professional

DayMonthYear

AEFI Record Number (for public health officials or QPPVs)

Record number used by national or regional PV centre

Status of Case

Supplemental document (e.g. CIOMS report)

Browse Files

VIGICARIB Reporting Form for Adverse Events Following Immunization (AEFI) for Health Professionals / PV Officers