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Adverse Event Reporting Form

Document adverse reactions following vaccination, including doses received, symptoms, and the medical follow-up provided, to support safety monitoring.

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Name

Nombre

Apellido

Birth Date

Phone Number

Gender

Male Female Non-binary Prefer not to say

Blood type

O positive O negative A positive A negative B positive AB positive

Select the vaccine brands you received

Pfizer Moderna Johnson & Johnson AstraZeneca Novavax Other

How many COVID-19 vaccine doses did you receive?

Date of 1st Dose

Date of 2nd Dose

Date of 3rd Dose

Date of 4th Dose

Date of adverse reaction

Please select the symptoms and diagnosis

Fever Fatigue Headache Allergic reaction Muscle pain Other

What treatment did you receive?

None Over-the-counter medication Hospital visit Prescribed medication Other

Please describe offered/prescribed medication and treatment

Which were the official reporting of the adverse reaction?

Treating doctor Health authority Vaccine manufacturer Hospital or clinic Not reported

What were your motivations for being vaccinated?

Protect myself Protect others Employer requirement Travel requirement Recommended by doctor Other

Which of the following statements have been told at site of vaccination?

I was informed of possible side effects I was informed of the vaccine's benefits I was given an information sheet I was told to wait 15 minutes for observation None of the above

Attitude to COVID-19 vaccination

Strongly supportive Supportive Neutral Hesitant Opposed

Further questions and comments

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