Vaccine Reaction Reporting Form
Adverse Event Following Immunisation
Click
here
to download a printable copy of the Vaccine Reaction Reporting form to be completed and submitted using an alternative method.
As a minimum please complete all
required
fields and then click
Submit
.
Report Lodgement Number
Person Vaccinated
First Name
Surname
Date of Birth
Postal Address
Suburb
State
(select)
SA
NT
VIC
WA
NSW
QLD
TAS
ACT
Postcode
Phone 1
Phone 2
Gender
Male
Female
Indeterminate
Intersex
Unspecified
Unknown
Aboriginal
Yes
No
Unknown
Torres Strait Islander
Yes
No
Unknown
Parent/Guardian Details (if applicable)
First Name
Surname
Phone 1
Phone 2
Person Reporting
Report Date
11/10/2024
Relationship to Patient
Self
Paramedic
Parent/Guardian
Pharmacist
Doctor
Nurse/Midwife
Other (please specify)
Other Relationship
First Name
Surname
Phone
Organisation Name
Email Address
Address
Suburb
Postcode
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
Yes
No
Contact the person vaccinated or guardian about participating in Immunisation Research
Yes
No
Immunisation Provider
Who provided the vaccine?
Doctor
Nurse/Midwife
Pharmacist
Other
Unknown
Location
GP
Council
Community Health
Aboriginal Health
Hospital
School
Pharmacy
Other (please specify)
Aged Care Facility
Unknown
Other Location
Organisation Name
Phone
Address
Suburb
Postcode
Medical History
Pregnant at the time of vaccination?
(select)
Yes
No
N/A
Unknown
Gestation weeks
weeks
Other vaccines or medications in last 4 weeks?
Yes
No
Unknown
Only if aged under 2 years
Illness at time of vaccination?
Yes
No
Unknown
Weeks Gestation
Unknown
Pre-existing Medical Conditions/Allergies?
Yes
No
Unknown
Birth weight (grams)
Unknown
Details
Vaccines Administered
Date of Vaccination
Time
(24 hr clock)
Vaccine Brand
Vaccine Antigens
Dose Vol.
Dose No.
Batch Number
Site
(select)
Abrysvo
Abrysvo Pregnant women 24 to 36 weeks
Act-HIB
Adacel
ADT Booster
Afluria Quad
Arexvy
AstraZeneca Vaxzevria
Bexsero
Beyfortus 100 mg 5 kg and greater
Beyfortus 50mg less than 5 kg
Boostrix
Boostrix-IPV
Engerix B Adult formulation
Engerix B Paediatric formulation
Fluad Quad
Fluarix Tetra
Flucelvax Quad
FluQuadri
Fluzone High-Dose Quad
Gardasil 9
Havrix 1440
Havrix Junior
H-B-Vax II Adult
H-B-Vax II PAEDIATRIC
Hiberix
Imogam RHIG
Imojev
Infanrix
Infanrix Hexa
Infanrix IPV
Influvac Tetra
IPOL
Ixiaro
Ixiaro 2 months to less than 3 years
JEspect
JEspect 2 months to less than 3 years
Jynneos
KamRAB
Menactra
MenQuadfi
Menveo
Merieux
M-M-R II
Moderna - Spikevax XBB.1.5
Moderna Spikevax Bivalent BA.4-5 Booster
Neisvac-C
Nimenrix
Novavax - Nuvaxovid
Pfizer Comirnaty
Pfizer Comirnaty Bivalent Booster BA.1
Pfizer Comirnaty Bivalent Booster BA.4-5
Pfizer Comirnaty Omicron XBB.1.5 - 10 mcg
Pfizer Comirnaty Omicron XBB.1.5 - 30 mcg
Pfizer Comirnaty Paediatric 5 to 11 years
Pfizer Comirnaty Paediatric 6 months to 4 years
Pneumovax 23
Prevenar 13
Priorix
Priorix-Tetra
ProQuad
Quadracel
Q-VAX
Rabipur
Rotarix
Shingrix
Stamaril
Tripacel
Trumenba
Twinrix
Typhim Vi
Vaqta Paediatric
Varilrix
Varivax
Vaxelis
Vaxigrip Tetra
Verorab
Vivaxim
Vivotif Oral Typhoid Vaccine/Capsule
Zostavax
(other)
ml
(select)
1
2
3
4
5
6
7
8
9
10
(select)
Left Leg
Right Leg
Left Arm
Right Arm
Oral
Left Ventrogluteal
Right Ventrogluteal
Unknown
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?
Yes
No
Unknown
Did the child have the 2 further recommended doses of paracetamol after vaccination?
Yes
No
Unknown
Has the vaccinated person ever had a COVID 19 infection?
Yes
No
Infection date:
(select)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(select)
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Nov
Dec
(select)
2019
2020
2021
2022
2023
2024
Vaccine Details
(if not selected above)
General Reaction
Yes
No
Unknown
Onset Date
Onset Time
(24 hr clock)
Time to onset of symptoms
days
hours
minutes
Recovered?
Yes
No
Unknown
Duration of symptoms
days
hours
minutes
Recovery Date
Details
Injection Site Reaction
Yes
No
Unknown
Onset Date
Onset Time
(24 hr clock)
Time to onset of symptoms
days
hours
minutes
Reaction Site
Left Leg
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Right Leg
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Left Arm
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Right Arm
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Left Ventrogluteal
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Right Ventrogluteal
Rash
around injection site
injected limb only
Pain
around injection site
restricting limb mobility
Swelling
around injection site
to nearest joint
from joint to joint
beyond the nearest joint
more than twice usual width
Other
Recovered?
Yes
No
Unknown
Duration of symptoms
days
hours
minutes
Recovery Date
Details
Treatment Details
Treatment Type
Paramedic
Pharmacist
Parental
Self
Nurse
GP
Hospital Emergency
Hospital Admission
Unknown
Number of Days Admitted
Date of discharge
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
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