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VAERS - Vaccine Adverse Event Reporting System
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Adverse Event
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Report Adverse Event Online
Step 1 of 5: Person Reporting Event
Form Completed By:
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Information Kept Confidential
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* Relation to Patient:
Choose a Relation
Vaccine Provider
Patient/Parent
Other
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First Name:
MI:
Last Name:
Address:
Address 2:
Address 3:
City:
State:
Choose a State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Republic of Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
US Virgin Islands
USA
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Foreign
Postal Code:
completed_plusfourcode
-
Phone Number:
(
)
completed_phone3
completed_phone4
-
Email Address:
Date Form Completed (Box 6):
02/15/2013
Have You Reported This Adverse Event Previously? (Box 20)
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No
To Health Department
To Doctor
To Manufacturer
Only for Reports Submitted by State Health Coordinator or Immunization Project
Immunization Project Report Number (Box 24):
Date Received by Immunization Project (Box 25):
(mm/dd/yyyy)