VigiCarib Vaccine Reporting Form

This form is intended for persons living in the Caribbean Community (CARICOM) or in other CARPHA Member States, who would like to submit a report of an unexpected or serious adverse event or adverse reaction that occurred with you or with someone you are a guardian for, after receiving a vaccine. Completion of this form is voluntary, and the information is sent to the country's Ministry of Health for follow up according to national policies. The patient's name does not need to be stated (initials may be used), but the name and contact of the reporter will be needed.

If the event being reported has not been medically confirmed, the person who is affected is advised to seek medical care or assistance from a health professional. Health professionals may submit their report using the form at: https://form.jotform.com/210037487099865

The report will be considered as 'preliminary' or 'unconfirmed', and it will be sent to the ministry of health for verification, as per national policies, procedures and criteria. 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.

The 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 identifier, alias, or Initials*

Please enter the initials, alias, or unique identifier of the person who experienced the adverse event

Patient Sex

Patient Age (when event occured)*

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

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

Please describe the adverse event or reaction, including how long it lasted for and if it has been resolved or if it is still affecting the person. *

Did the patient see a doctor about the event?

YesNo

What date did the adverse event start*

DayMonthYear

Please tell us about the Outcome of the Adverse Event

If the patient has any other conditions, or is using other medicines, or had other reactions in the past, you can list them here, including if pregnant.

Enter as much information as possible based on availability

Reporter Name*

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

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

Area CodePhone Number

Your Email

example@example.com

What is your role?

VIGICARIB Reporting Form for Adverse Events Following Immunization (AEFI) for Patients / Caregivers