COVID 19 Adverse Event Following Immunisation Reporting Form

Referral to: Prevention Division QHEALTH: PQ4000000B5

PLEASE ONLY COMPLETE THIS FORM FOR COVID 19 SERIOUS, UNCOMMON OR UNEXPECTED
ADVERSE EVENTS

Vaccinated person details:
Patient Name: Re: <<Patient Demographics:Full Name>>
Gender: <<Patient Demographics:Gender>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>

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

Indigenous status: <<Patient Demographics:ATSI>>

Important medical history:
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Was the person ill at the time of vaccination? <<Was the patient ill at the time of vaccination?>>
If yes, please specify: <<Details of patient's illness>>

Has the vaccinated person had previous reactions to vaccinations? <<Previous reactions to vaccinations?>>
If yes, please specify: <<Details of previous vaccination reactions>>

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Vaccination provider details (if different from reporter details below):
As per reporter details below? (Y/N): <<Did you provide the vaccination?>>
OR
Provider Name: <<Vaccination provider - Name>>
Practice Name: <<Vaccination Provider - Practice Name>>
Address: <<Vaccination Provider - Address>>
Phone: <<Vaccination Provider - Phone Number>>
Email: <<Vaccination Provider - Email>>
Fax: <<Vaccination Provider - Fax>>
Profession: <<Vaccination Provider - Profession (e.g. GP, RN...)>>
Clinical Setting: <<Vaccination Provider - Clinical Setting>>

Address of service where vaccine was administered (if different from above)
Name of practice/clinic/provider: <<If not administered at at above addr - PracticeName>>
Address: <<If not administered at at above addr - Address>>
Phone: <<If not administered at at above addr - Phone>>
Email: <<If not administered at at above addr - Email>>

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Reporter details:
Name: <<Miscellaneous:Current User>>
Practice name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Email: <<Practice:E-mail>>
Date of report: <<Miscellaneous:Date>>

Reporter type: (type 'Y' next to the option that applies)<<Miscellaneous:Current User>>
Medical practitioner: <<Reporter profession - Medical Practitioner>>
Registered nurse: <<Reporter profession - Registered Nurse>>
Other - Please specify: <<Reporter profession - Other, please specify>>

If you require further information following an adverse event please contact your local Public Health Unit.

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Consent statement:
I, the reporter agree to be contacted for further follow up regarding this adverse event if necessary (Y/N): <<I agree to be contacted if necessary>>

Name: <<Miscellaneous:Current User>> Date: <<Miscellaneous:Date>>

Please advise the parent/patient that contact details will be used to follow up if information is needed.

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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.

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Management of event: (type 'Y' for any that apply)
Nurse assessment: <<Management of event - Nurse assessment>>
Medical assessment: <<Management of event - Medical assessment>>
GP Assessment: <<Management of event - GP assessment>>
Hospital emergency department: <<Management of event - Hospital emergency dept>>
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 the treatment/care provided>>

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Once you have completed the form you can either:
1. Send via Medical-Objects or
2. Attach it to an email for sending to COVID_AEFI@health.qld.gov.au

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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 v2.0 MD 26052021