Please note all adverse event reported here must also be reported in VAERS system

Immunization Information

Patient Medical Facility : {{editDoseData.administeredFacilityName}}
Date Received : {{editDoseData.dateReceived}}
Reason for Visit : {{editDoseData.reasonForVisitDesc}}
Vaccine ID : {{editDoseData.vaccineId}}
Administration Route : {{editDoseData.vaccAdminRouteDescr}}
Administration Site : {{editDoseData.vaccAdminSiteDescr}}
Combo : {{editDoseData.combo}}
Lot Number : {{editDoseData.lotNumber}}
Date Added : {{editDoseData.dateCreated}}

Adverse Event Information

Advsere Event is required
Please enter a valid date Date Reported is required Date Reported cannot be earlier than Immunization Date Date Reported cannot be later than today
Patient Recovered is required Patient death date cannot be given if Patient recovered is Recovered
{{patientRecoveredDescr}}
Please enter a valid date Date is required Date of death cannot be earlier than date of birth Date of death cannot be later than today
 

Details (Check All Appropriate)

{{lov.descr}}
Please enter a valid no Days Required
None of the Above

Describe Adverse Event

{{model.comments}}
 

Relevant Diagnostic Tests/Lab Data

{{model.labTest}}

Post Vaccinations

Invalid Lot Number
Please enter a valid date Vaccination Start Date cannot be later than today Vaccination Start Date cannot be earlier than Immunization date Vaccination Start Date cannot be earlier than Immunization date
Invalid Lot Number
Manufacturer Number

Post Medications

Medication Number
Start Date is required Please enter valid date Medication Start Date cannot be earlier than Immunization date Medication Start Date cannot be earlier than todays date Medication Start Date cannot be earlier than Immunization date Medication Start Date cannot be later than todays date
Please enter valid data Medication End Date cannot be earlier than Medication Start date Medication End Date cannot be later than today Medication End Date cannot be earlier than Immunization Date
Invalid Lot Number