Vaccinevigilance – pharmaadvance.in

Patient Information *

Patient identity is held in strict confidence — no full name required

1. Patient Initials *

2. Age or Date of Birth *

3. Gender *

M F Other

4. Weight (in Kg.)

Reg. No. / IPD No. / OPD No. / Vaccination Card No.

Vaccine(s) Administered *

Details of all vaccines given — including batch number and site of injection

S.No.	5. Vaccine Name (Brand/Generic)	Manufacturer	Batch/Lot No. *	Expiry Date	Dose No.	Dose (ml)	Route	Site	Date of Vaccination	Time of Vaccination	Diluent (if applicable)	Diluent Batch
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Causality Assessment (WHO-UMC / Brighton)

Preliminary assessment — final determination by AMC

15. Causality Assessment

16. Brighton Collaboration / WHO-UMC Level

Concomitant Medications

All medications taken within 4 weeks of vaccination — including self-medication & herbal products

S.No.	Name (Brand/Generic)	Dose	Route	Frequency	Date Started	Date Stopped	Indication
i

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Upload Documents & Investigation Reports

Vaccination card · Lab reports · Discharge summary · Reaction photos · Any clinical evidence

💉 Vaccination card 📷 Reaction / Rash photos 🧪 Lab reports 🫀 ECG strip 📄 Discharge summary 🩻 Imaging reports

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Click to browse files or drag & drop here

JPG · PNG · PDF · Max 10 MB per file · Up to 5 files

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Additional Information

Cold chain status, vaccination session details, any other relevant observations

Reporter Details *

Reporter identity is confidential — submission does not imply legal liability

17. Name & Address *

Institution / Hospital / PHC / CHC *

Pin Code

Contact No.

Occupation / Designation *

18. Date of this report

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Patient identity is held in strict confidence. Submission does not constitute an admission that healthcare personnel, manufacturer, or product caused the event. This form does not replace emergency clinical management. Reports are sent to AMC → NCC-PvPI → WHO Uppsala Monitoring Centre.

Also report directly: pvpi.ipc@gov.in · Helpline: 1800-180-3024

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AEFI Report Submitted Successfully

Your report is saved and pending faculty review before PvPI submission.

The Pharmacology Department has been notified by email.
After faculty verification, the report will be forwarded to the PvPI portal (pvpi.gov.in).

Adverse Events Following Immunisation (AEFI) Reporting Form

AEFI Report Submitted Successfully