COVID COVID 19 Adverse Event Following Immunisation Reporting Form v1.1 BP 210621
COVID 19 Adverse Event Following Immunisation Reporting Form
Referral to: Prevention Division QHEALTH: PQ4000000B5
Re: <PtName>
PLEASE ONLY COMPLETE THIS FORM FOR COVID 19 SERIOUS, UNCOMMON OR UNEXPECTED ADVERSE EVENTS
Vaccinated person details	Vaccination provider details	
Patient Name: Re: <PtName>
Gender: <PtSex>
Date of Birth:DOB: <PtDoB>
Address: <PtAddress>

Name of parent/guardian/substitute decision maker (if relevant):
<Name of parent/guardian/substitute decision maker>
Phone: <Phone - parent/guardian/substitute decision maker>
Email: <Email - parent/guardian/substitute decision maker>

Indigenous status: <PtEthnicity>

Important medical history: <Important Medical History>

Was the person ill at the time of vaccination? <Was the person ill at the time of vaccination? >
If Yes - please specify: <If person ill at the time of vaccination please explain>

Has the vaccinated person had previous reactions to vaccinations? <Has the vaccinated person had previous reactions >
If Yes - please specify: <If previous reactions please explain>
	Provider Name: <UsrName>
Practice Name: <LocationName>
Address: <LocationAddress> 
Phone: <LocationPhone>
Email: <LocationEmail>
Fax: <LocationFax>

Profession: <Vaccination Provider Profession>
If Other Profession: <If Other Profession>
Clinical setting: <Clinical setting>
If Other Clinical setting: <If Other Clinical setting>
Address of service where vaccine was administered: <Address of service where vaccine was administered>

If not administered at practice above:

Medical Practitioner Name: <If not administered at your clinic - Practitioner Name>
Administering Practice Name: <If not administered at your clinic - Practice Name>
Address: <If not administered at your clinic - Address>
Phone: <If not administered a your clinic - Phone Number>
Email: <If not administered at your clinic - Email>  
	
Allergies: 
<Reactions> 	
Reporter details (if different from vaccinated person details or vaccination provider details) 	
As per vaccinated person’s details (above): <Reporter - Vaccinated Person >
As per vaccination provider details (above): <Reporter- Vaccination Provider >
OR
As per vaccination provider details(below):
Full name: <If not above - Reporter Full Name>
Practice name: <If not above - Reporter Practice Name>
Address: <If not above - Reporter Address>
Phone number: <If not above - Reporter Phone Number>
Email: <If not above - Reporter Email>

Date of Report: <TodaysDate>

Reporter Type: <Reporter - Type>
If Other Reporter Type: <If Other Reporter Type>

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 further  follow up regarding this  adverse event  if  necessary. <I agree to be contacted and followed up if necessary>

Name: <UsrName>                                                 Date: <TodaysDate>
Please advise the parent/patient that contact details will be used to follow up if information is needed.
	
Vaccine details	
Vaccine (brand name)	Dose number
(e.g. 1 of 2)	Batch Number	Date given	Time given	Injection site	

						
						
Serious, uncommon or unexpected COVID-19 adverse events	
Symptom(s)	Onset date	Onset time	Resolved date (leave blank if ongoing)	Resolved time 	
Redness / tenderness / itching at injection site					
Generalised itch
					
Enlarged lymph nodes
					
Anaphylaxis or anaphylactic shock*^
					
Demyelination or neurological event *
					
Rash *
					
Facial tingling / drooping *
					
Death *#					
Thrombosis (including Pulmonary Embolism and Deep Vein Thrombosis) * 					
Other significant symptoms *T (please specify)
					
Additional description of reaction/s

*   Patients with these symptoms might be referred to a Public Health Unit (PHU) for further assessment and review.
^   AEFI forms for patients with suspected or diagnosed anaphylaxis must be accompanied with a completed Post COVID-19 Vaccination Suspected Anaphylaxis Reporting Form.
T   Adverse Events of Special Interest (AESI) following COVID-19 Vaccination has been developed by the TGA.
#   All Fatal AEFI must be reported to the Queensland Coroner and Vaccine Command Centre as soon as practical.	
Management of event: (tick as many as apply)

Nurse assessment: <Management of event - Nurse assement>
Medical assessment: <Management of event - Medical assessment>
GP Assessment: <Management of event - GP Assessment >
Hospital emergency department: <Management of event - Hospital emergency department>
Hospital admission: <Management of event - Hospital admission>
Self: <Management of event - Self>
Unknown: <Management of event - Unknown>
None: <Management of event - None>
Other, please specify: <Management of event - Other, please Specify>

Please specify the treatment / care provided (e.g. antibiotics, adrenaline, advice, counselling, etc.):
<Please specify treatment/care provided >
	
Once you have completed this form, you can either.
1.	Send via Medical-Objects (QHEALTH, Prevention Division  PQ4000000B5) or
2.	Attach it to an email for sending to COVID_AEFI@health.qld.gov.au. 

Privacy statement	
 The Information Privacy Act 2009 sets out the 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 Queensland Health to record the reporting of AEFI to Queensland Health for inclusion on a state register. If further follow up is required following an adverse event the information stored on the Notifiable and Other Conditions register will be used. Adverse Events Following Immunisation (AEFI)reports collects details such as the vaccinated person’s name,contact information andrelevanthealth information.Details pertaining to the adverse event,important medical history relevantfor follow up following the adverse event,details of the provider who administeredthe vaccine,reporter details andvaccination details are requested andrecordedfor each AEFI report.AuthorisedQueensland Healthstaffmayaccesstheinformation for the purpose of clinical follow up andmonitoring. Personalinformation will not be accessed by orgiven to anyother person ororganisation withoutpermissionunless permittedor 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	

COVID 19 Adverse Event Following Immunisation Reporting Form v1.1 BP 210621