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6. Revised AEFI Reporting Form

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66 views2 pages

6. Revised AEFI Reporting Form

Uploaded by

zahrabinteyusuf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Expanded Programme on Immunization (EPI)

Adverse Events Following Immunization (AEFI) Reporting Form

AEFI EPID No: PAK/______/______/_____/AEFI/__________


( PAK/Province ID/District ID/Year/Per/Case Serial # # # #)
Part-1: For use by reporting health facility and/ or investigation team and District Health Office
Reported by Passive Surveillance ⎕ Active Surveillance ⎕ Media Reporting ⎕
Reported from Public Health Facility ⎕ Community ⎕ Private Sector ⎕
Case Report

Name of Reporting Site ________________________ Reporting Person ______________________ Designation ________


Union Council _______________Tehsil/Town/Taluka __________________District ________________ Province _______
Place of Vaccination Govt. Dispensary . MCH . BHU . RHC . THQ . DHQ . Teaching
Military Health Facility . Outreach . LHW . Private Clinic/Hospital .
Vaccinated By: _________________________Designation : ________________________ Phone No. _________________
Patient's Name ______________________________ Father's Name _______________________________ Sex Male ⎕
Date of Birth ____/_____/_______ Age: ____in months. Contact No. 1 ___________________ Contact No. 2 ________
Demographic
Details

Complete Address of Patient: Village/Street/Mohalla _______________________________________________________


Nearby landmark _____________________ Union Council ____________________ Tehsil/Town/Taluka_____________
District _________________________ Province/Administrative Area___________________ Nationality _____________
Vaccination History
Vaccination Details

Received Diluent Vaccination Vaccination Dose Manufacturer Site of Batch /


Vaccine/s (If Applicable) Date Time (1st, 2nd etc.) Name Administration Lot Number

Clinical Description
Severe Local Reaction  Fever > 38° C  Redness and swelling at the injection site  Injection site abscess 
Clinical Information

Anaphylaxis  Fits & Seizures  Unconsciousness  Nausea & Vomiting  Diarrhoea  Headache  Respirator
Swelling of body and face  Other  What if Other ____________________________________________________
Congenital anomaly / birth defect  Persistent or significant disability or disability (paralysis)  Life threatening 
Hospitalization or prolongation of existing hospitalization (e.g. encephalopathy, seizures aseptic meningitis)  Death 
Date and Time of onset of symptoms ____/_____/_______ - ___:___ Was the patient hospitalized Yes  No , If Ye
Hospital _________________________________________ Address : __________________________________________
Date and Time of hospitalization ____/_____/_______ - ___:___

History of Present Illness


Patient Medical History

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________
Past History (including history of similar reaction or other allergies), medication and other relevant information e.g., othe
additional sheet if needed) ____________________________________________________________________________
Recovering  Recovered  Recovered with sequalae  Not Recovered  Unknown 
Outcome

Died  Date if died ____/_____/_______ Autopsy Done Yes  No  Unknown 

Type of AEFI Minor  Serious  Cluster of AEFI cases Yes  No 


Investigated by (Name) __________________ Designation_______________ Signature____________ Date ____ / __
Type of Case

National/Provincial level to complete Date report received at National Level ____/_____/_______


Comments / Remarks
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________
Note: The AEFI case investigation should be initiated within 24 hours of notification . Submit the report to local health facility incharge who will send to CEO/DHO office. All fields
are compulsory/mandatory to be filled. In case of emergency, notify AEFI focal person immediately.

Adverse Events Following Immunization (AEFI) Investigation Form V.1.0 form developed in July 2024.
Expanded Programme on Immunization (EPI)
Adverse Events Following Immunization (AEFI) Reporting Form

Note: The AEFI case investigation should be initiated within 24 hours of notification . Submit the report to local health facility incharge who will send to CEO/DHO office. All fields
are compulsory/mandatory to be filled. In case of emergency, notify AEFI focal person immediately.

Adverse Events Following Immunization (AEFI) Investigation Form V.1.0 form developed in July 2024.

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