AEFI CASE REPORTING FORM

AEFI REPORTING ID : (TO BE ALOTTED BY BIOMED)

(To be submitted within 24 hours of case notification)

State		District
Block/ Ward		Village/ Urban Area
Address of the Site:
Notified by (Name):		Designation (please circle): health worker/ government doctor/ private practitioner/ community/ media/ others (specify)
Date:
Contact phone number (with STD code):

Patient Name:

Age/ Date of Birth:

Sex

Male

Female

Father’s Name/ Husband Name

Complete Residential Address of the case with landmarks (Street name, house number, village, block, tehsil, Pin No. etc.)

Date of vaccination	D	D	M	M	Y	Y	Y	Y	Time of vaccination	H	H	M	M	(AM	PM)
Address of session site: Place of vaccination :Govt Health Facility/Outreach/Private Health facility/others
Date of First Symptom	D	D	M	M	Y	Y	Y	Y	Time of First Symptom	H	H	M	M	(AM	PM)
Details of vaccine, diluents & Vitamin A given to the patient on day of event
Name of vaccines received (write vaccine & diluent details in separate rows)	Dose no. (zero/ first/ second etc. as applicable)		Name of manufacturer		Mfg. date		Expiry date		Date of opening of vial		Time of opening the vial (for reconstituted vaccine)		No. of OTHER beneficiaries who received vaccine from the SAME vial in this session
Details of hospitalization:
Hospitalization: No/Yes (date)	D	D	M	M	Y	Y	Y	Y	Time of Hospitalization	H	H	M	M	(AM	PM)
Name and address of hospital (if hospitalized):
Current Status (encircle)				Death/ Still Hospitalized/ Recovered & Discharged/ Left Against Medical Advice (LAMA)/Recovered completely and discharged/Not Hospitalized.
If Died, Date of Death	D	D	M	M	Y	Y	Y	Y	Time of Death	H	H	M	M	(AM	PM)
Post mortem done? (encircle)					Yes**/ No/ Planned on (Date)					If Yes, Date Time
Describe AEFI (signs and symptoms):
Suspected adverse event(s) (tick at least one):
Severe local reaction								Seizures
>3 days								febrile
>Beyond nearest joint								afebrile
Abscess				Sepsis				Encephalopathy				Toxic Shock Syndrome
Thrombocytopenia					Anaphylaxis					Intussusception
Fever ≥ 39 ºC (102 ºF)								Hypotonic hypo-responsive episode (HHE)
Acute flaccid paralysis								Sudden Unexplained death syndrome.
Death due to any reason other than above – specify
Hospitalization due to any reason other than above – specify
Disability								Cluster – is this case part of a cluster? Yes/ no/ unknown
If yes, no of other cases in the cluster											(use separate form for each case in a cluster)
Signature and Date of reporting/ verifying person:								Email Id:
Proposed date of investigation: -
Review By : (Sign/Date) Notes/ Comments: