AEFI Report – PharmaNotes

1 — CLIENT AND REPORTING SOURCE INFORMATION

Client Last Name *

Given Name(s) *

Ontario Health Card #

Date of Birth *

Sex

Male Female Other Unknown

Parent/Guardian/Caregiver Name

Telephone #

Address

City

Postal Code

Reported to Public Health by

Relationship with Case

Date of Report

Form Completed By

Contact Information of Reporter (if different)

2 — IMMUNIZATION INFORMATION

Date (yyyy-mm-dd) *	Time (HH:MM)	Manufacturer / Trade Name *	Lot #	Lot Exp. Date	Dose #	Site	Route

Immunization Error

No Unknown Yes*

*Describe in Section 5

Where Vaccine Administered (e.g., pharmacy)

Administered By – Name

Designation

3 — ADVERSE EVENT INFORMATION

A. Report only events which cannot be attributed to co-existing conditions.
B. Reactions marked ★ must be diagnosed by a physician or nurse practitioner.
C. Record time to onset (from vaccination) and duration in minutes, hours, or days.

4 — MEDICAL HISTORY

Provide a detailed description of the client's medical history (e.g. immunocompromised, chronic illness, concomitant medications, history of allergies).

Previous History of AEFI

No Unknown Yes*

*Describe in Section 5

Pregnant at Time of Immunization

No Yes Unknown

5 — COMMENTS FURTHER DESCRIBING THE ADVERSE EVENT(S)

Provide a detailed description including all signs and symptoms, investigation, treatment, hospitalization details, and description of previous AEFI or immunization error.

6 — HEALTH CARE UTILIZATION & OUTCOME

Outcome to be updated by the Public Health Unit when investigation is complete.

Medical Consultation (non-urgent)

Yes No

Date of Consultation *

Seen in Emergency Department

Yes No

Date of ER Visit *

Admitted to Hospital Because of Event

Yes No

Admission Date *

Discharge Date *

Health Professional Attending – Name

Health Professional – Address

Name of Facility Where Event Was Attended (e.g., hospital name)

OUTCOME *

Recovered Not yet recovered Persistent or significant disability / incapacity Unknown Death

Describe Outcome

Date of Outcome