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.)	

																				
																				
P	I	N	-							P	H	O	N	E	-					

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	Batch/ lot no.	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	a.m.	p.m.	
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: