Adverse event following immunisaon/vaccine failure Quesons are followed by answer fields. Use the ‘Tab’ key to navigate through. Replace Y/N or Yes/No fields with your answer. Privacy statement The Northern Territory Government values and is commied to protecng your privacy. We handle your personal informaon in accordance with the informaon privacy principles in the Informaon Act 2002 . We will only use personal informaon contained in the forms to provide you with a department service or program. We don’t share informaon about you with other government agencies or other organisaons without your permission unless: it’s necessary to provide you with a service that you have requested it’s required or authorised by law it will prevent or lessen a serious and imminent threat to somebody’s health. We recommend you read the privacy policy at hps://health.nt.gov.au/freedom-of-informaon . Fields marked with asterisk (*) are mandatory. Fields marked with caret (^) are office use only. Secon 1 – Paent details HRN Given name* Family name* Date of birth* Age at me of event* Sex* Body weight* Ethnicity* Australian please select ethnic sub-group below: Australian Australian-Aboriginal Australian-Aboriginal and Torres Strait Islander Torres Strait Islander Norfolk Islander Other please complete below secons: Ethnicity: (e.g. New Zealand) Ethnic sub-group: (e.g. Maori) If paent is under 18 years of age* Parent/Guardian given name Parent/Guardian family name Residenal address* Department of HEALTH Last updated 25 June 2021 Page 1 of 6
Transcript
Adverse event following immunisation/vaccine failureQuestions are followed by answer fields. Use the ‘Tab’ key to navigate through. Replace Y/N or Yes/No fields with your answer.
Privacy statement The Northern Territory Government values and is committed to protecting your privacy. We handle your personal information in accordance with the information privacy principles in the Information Act 2002.
We will only use personal information contained in the forms to provide you with a department service or program. We don’t share information about you with other government agencies or other organisations without your permission unless:
it’s necessary to provide you with a service that you have requested it’s required or authorised by law it will prevent or lessen a serious and imminent threat to somebody’s health.
We recommend you read the privacy policy at https://health.nt.gov.au/freedom-of-information.
Fields marked with asterisk (*) are mandatory.Fields marked with caret (^) are office use only.
Australian Australian-Aboriginal Australian-Aboriginal and Torres Strait Islander Torres Strait Islander Norfolk Islander
Otherplease complete below sections:
Ethnicity: (e.g. New Zealand)
Ethnic sub-group: (e.g. Maori)
If patient is under 18 years of age*Parent/Guardian given name
Parent/Guardian family name
Residential address*
Department of HEALTHLast updated 25 June 2021Page 1 of 6
Adverse event following immunisation/vaccine failure
Fields marked with asterisk (*) are mandatory.Fields marked with caret (^) are office use only.
Suburb* State/Territory* Post code*
Section 2 – Patient medical history
Allergies*
Congenital abnormalities*
Other significant conditions / comorbidities*
Current medications*(Details of medicines including those taken in the last 3 months)
Were other vaccines administered within 4 weeks prior to the suspected vaccine?* If yes, please provide details of the vaccine/s administered prior to the adverse reaction Yes No
Vaccine Brand Dose
Has the patient had a previous vaccine reaction? *If yes, please provide details on whether the vaccinated person has experienced reactions to previous vaccinations
Yes No Unknown
Pregnancy status* Yes No Unknown
Department of HEALTHPage 2 of 6
Adverse event following immunisation/vaccine failure
Fields marked with asterisk (*) are mandatory.Fields marked with caret (^) are office use only.
Has the vaccinated person ever had a COVID 19 infection? * Yes No Unknown
If yes, please provide the last known date the vaccinated person had a COVID 19 infection Date: ______/______/__________
Section 3 – Vaccine details* (Details of the vaccine/s which you suspect caused the reaction)
Date vaccine/s were administered*
Vaccine, brand and dose(select vaccine/s below)
Trade/brand name (circle brand)
Dose no.
Batch # Route of administration(I) Intramuscular / (S)Subcutaneous / (O) Oral / Other -please specify
Injection siteSpecify site and left or right side (e.g. left buttock)
Section 4 – Reaction details*(Details of the adverse reaction)
Reaction description*
Onset date of event/reaction*
End date of event/reaction*
Select the action/s taken to manage the reported reactions or adverse event(s) *
None Nurse assessment GP assessment Helpline Self
Hospital emergency department Hospital admission (provide dates below*) Unknown
Hospital admission date
Hospital discharge date
Was the person ill at the time of administration of the suspected vaccine/s? * Yes No
Select the outcome of the event* Recovered/resolved Recovering/resolving Not recovered/not resolved/ongoing
Recovered/resolved with sequelae
Fatal Unknown
Describe the outcome of the event*E.g. if the patient recovered, in what time frame. If they have not recovered, describe the current situation
Department of HEALTHPage 4 of 6
Adverse event following immunisation/vaccine failure
Section 4 – Reaction details*(Details of the adverse reaction)
Section 5 – Vaccination provider details* (Details of the person who administered the vaccine)
Organisation name*
Organisation type* Clinic Council clinic Aged Care Facility
School Hospital Workplace
Public Health Unit Unknown
Given name*
Family name*
Email address *
Phone*
Organisation street address*
Suburb* State/Territory* Post code*
Section 6 – Reporter details* (Details of the person reporting this adverse event)
Do you consent to being contacted regarding the adverse event?* Yes No
Role/Designation* Nurse/Midwife Aboriginal Health Practitioner Physician
Pharmacist Other health professional Consumer or non health professional
Did you administer the vaccine?* YesNo further information required
Noplease complete section below*
Organisation type Clinic Council clinic Aged Care Facility
School Hospital Workplace
Public Health Unit Unknown
Given name
Family name
Email address
Department of HEALTHPage 5 of 6
Adverse event following immunisation/vaccine failure
Section 5 – Vaccination provider details* (Details of the person who administered the vaccine)
Phone
Organisation street address
Suburb State/Territory Post code
Office use only^
Full name^
Job title^
Phone or email^
Reference number^
Further information Email your completed form to [email protected] your local Centre for Disease Control for any further advice, or email [email protected], call 08 8922 8044 or fax 08 8922 8310.d of form
