Practice/clinic/provider name:
Surname First name Surname First name
Gender
Male
Female
Other, please specify
Date of Birth
Street Address
Street Address
Suburb State Postcode
Suburb State Postcode
Name of parent/guardian/substitute decision maker (if relevant)
Mobile
Phone Home Mobile
Email
Fax
Email
Indigenous status
Profession
Is the person of Aboriginal or Torres Strait Islander origin?
Medical practitioner Registered Nurse
Other, please specify
Clinical setting
Aboriginal Torres Strait Islander
Aboriginal and Torres Strait Islander
Not Stated/UnknownNot Aboriginal or Torres Strait Islander
GP practice Aged care facility
Hospital Unknown
Other, please specify
Important medical history
(e.g. requires regular medical follow up)
Address of service where vaccine was administered
As for vaccination provider
(above) or
Name of practice/clinic/provider
Allergies
Was the person ill at the time of vaccination?
Street Address
No Yes - please specify
Has the vaccinated person had previous reactions to vaccinations?
Suburb State Postcode
No
Yes - please specify
Unknown
Mobile
Email
Adverse Event Following
Immunisation Reporting Form
November 2023
Date Report Received
QH ID no.
TGA ID no.
PLEASE COMPLETE THIS FORM FOR ALL SERIOUS, UNCOMMON OR UNEXPECTED ADVERSE EVENTS INCLUDING COVID-19*
ORAs per vaccination provider details (above)
Surname First name Practice Name (if relevant)
Street Address Suburb State Postcode
Phone landline (incl. area code) Phone mobile
Email Date of report
Reporter type
Medical practitioner
Registered nurse Vacci
nated person Parent/guardian/substitute decision maker
Public Health Unit
If you require further information following an adverse event, please contact your local Public Health Unit.
Consent statement
I, the reporter, agree to be contacted for futher follow up regarding this adverse event if necessary.
Yes No
Name
Date
Please advise the person/parent/guardian/substitute decision maker that contact details will be used to follow up if information is needed.
Vaccinated person details Vaccination provider details
Pharmacy
Pharmacist
Phone Oce
School Immunisation Program
As per vaccinated person’s details (above) OR
Reporter details (if dierent from vaccinated person details or vaccination provider details)
Phone Oce
Oce Use Only
Pharmacist
Other, please specify
Vaccine details
Vaccine (brand name)
Dose number
(e.g. 1 or 2)
Batch Number Date given Time given Injection site
Serious, uncommon or unexpected adverse events
Symptom(s)
Redness/tenderness/itching at injection site
Generalised itch
Route of
RL LL NAID IN U
RL LL NA
ID IN U
RL LL NA
ID IN U
RL LL NA
ID IN U
RL
LL
NA
ID IN U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
RL LL NA
ID IN U
RL
LL
NA
ID IN U
RL LL NA
ID IN U
RL
LL
NA
ID IN U
RL
LL
NA
ID IN U
RL LL NA
ID IN U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
SCIMO
RA LA U
administration
Onset date Onset time Resolved date (leave blank if ongoing) Resolved time
Enlarged lymph nodes
Anaphylaxis or anaphylactic shock*
Demyelination or neurological/event*
Rash*
Facial tingling/drooping*
Death*
Thrombosis (inc. Pulmonary Embolism and Deep
Vein Thrombosis)*
(please specify)
Additional description of an adverse reaction/s
*
All adverse event reports are referred to a Public Health Unit for further assessment and review.
T
Adverse Events of Special Interest (AESI) following COVID-19 Vaccination has been developed by the TGA.
using the AEFI reporting process under the
Public Health Act 2005.
#
Other signicant symptoms
T
#
#
All Fatal AEFI must be reported to the Queensland Coroner. This does not replace the requirement for a death to be reported to Queensland Health
Adverse event details:
Onset of event: Date Time
Description of events, including timeline of occurrences (please provide separate page if needed):
Adverse Event Vaccine Administration Error
(Please tick a box)
The Information Privacy Act 20
09 sets out ways in which a health agency can collect personal information for the purpose of reporting Adverse Events Following
Immunisation (AEFI). The Public Health Act 2005 requires the AEFI to be reported to Queensland Health for inclusion on the Notiable Conditions Register (NoCS).
If further follow up is required following an adverse event, the information stored on the Notiable Conditions Register will be used. AEFI reports and collects
details such as the vaccinated person’s name, contact information and relevent health information. Details pertaining to the adverse event, important medical
history relevant for follow up following the adverse event, details of the provider who administered the vaccine, reporter details and vaccination details are
requested and recorded for each AEFI report. Authorised Queensland Health sta may access the information for the purpose of clinical follow up and monitoring.
Personal information will not be accessed by or given to any other person or organisation without permission unless permitted or required by law. For information
about how Queensland Health protects personal information, or to learn about the right to access your own personal information, please see our website at
www.health.qld.gov.au/system-governance/records-privacy
All reports are provided to the Therapeutic Goods Administration (TGA) to be entered into the TGA’s Australian Adverse Drugs Reactions System (the ADRS).
Information about how the TGA uses adverse event information that is reported is available at www.tga.gov.au/safety/problem.htm
Date
Signature
Management of event: (tick as many as apply)
Details:
Nurse assessment Medical assessment GP assessment
Pharmacist
Hospital emergency department
Hospital admission
Self
Unknown None Other, please specify
Please specify the treatment/care provided (e.g. antibiotics, adrenaline, advice, counselling, etc.):
.Click ‘Save As’ button to save the form for your records. Attach to an email for sending to [email protected]
. Click the ‘Print’ button, scan the form and then attach it to an email for sending to CDIS-NOCS-Support @health.qld.gov.au
. Open the form in Acrobat desktop and click ‘Email’ button to send to [email protected]
(Note: This requires the latest version of Adobe Acrobat and does not save the form for your records)
. Fax the form to ()  
Privacy statement
Clicking the ‘Reset Partial’ button will maintain the data entered in
the Vaccination Provider Details and Reporter Details sections.
However, all the other information in the form will be removed.
Clicking the ‘Reset All’ button will
remove all the information from this
form.
Save As Print Email
Reset Partial
END OF FORM
OR
OR
OR
Reset All
Once you have completed this form, you can either:
Oce use only - Public Health Unit
Is follow-up of the person required?
No Yes —Timeframe for follow up
Same day Next working day Next 60 days
Date of admission Date of discharge