SA Health
As a minimum please complete all required fields and then click Submit.
Person Vaccinated
First Name Surname Date of Birth
Postal Address Suburb State
Postcode
Phone 1 Phone 2
Gender
Aboriginal
Torres Strait Islander
Parent/Guardian Details (if applicable)
First Name Surname
Phone 1 Phone 2
Person Reporting
Report Date 17/09/2019
Relationship to Patient
First Name Surname Phone
Organisation Name
Email Address
Consent
Consent given for the Immunisation Section, Communicable Disease Control Branch to:
  • Contact the person vaccinated or guardian and/or the health provider regarding the event
  • Contact the person vaccinated or guardian about participating in Immunisation Research
Immunisation Provider
Who provided the vaccine?
Location

Organisation Name Phone
Address Suburb Postcode
Medical History
Other vaccines or medications in last 4 weeks? Only if aged under 2 years
Illness at time of vaccination? Weeks Gestation   
Pre-existing Medical Conditions/Allergies? Birth weight (grams)   
Details
Vaccines Administered
Date of Vaccination Time   (24 hr clock)
Vaccine BrandVaccine AntigensDose Vol.Dose No.Batch NumberSite 
 ml Remove
If Bexsero vaccine was administered, and the child is less than 2 years old, did they receive
paracetamol before or at the time of vaccination?
Did the child have the 2 further recommended doses of paracetamol after vaccination?
Vaccine Details
(if not selected above)
General Reaction
Onset Date Onset Time   (24 hr clock)
Time to onset of symptoms   days      hours      minutes
Recovered?
Duration of symptoms   days      hours      minutes
Recovery Date
Details
Injection Site Reaction
Onset Date Onset Time   (24 hr clock)
Time to onset of symptoms   days      hours      minutes
Reaction Site
Recovered?
Duration of symptoms   days      hours      minutes
Recovery Date
Details
Treatment Details
Treatment Type
Treatment Received
Organisation Name Phone
Files and Documents
You can upload up to 5 files with your report including photos and pdf documents.
Please note that the combined size of all files uploaded cannot exceed 16 MB.
  
File / Document 1  
File / Document 2  
File / Document 3  
File / Document 4  
File / Document 5