Vaccine Adverse Event Reporting

1. Are you reporting this adverse event for yourself?

2. Are you reporting this adverse event for someone else?

3. If you are reporting for someone else, what is your position relative to the patient?

4. Is the patient male or female?

5. What was patient’s age at the time of the vaccination?

6. What was patient’s age at the time of the time of the reaction?

7. What is patient’s weight?

8. Which vaccine was taken?

9. In which continent was the vaccine administered?

9a. Please Specify the country where the vaccine was administered?

9b. If vaccine was administered in USA which state was it administered in?

9c. If vaccine was administered in canada which province was it administered in?

10. How many doses of vaccine were administered?

11. If more than one dose was taken, were they the same vaccine eg. from the same manufacturer?

12. If more than one dose was taken, which vaccines were they eg. Who were the different manufacturers?

13. When was the first dose of vaccine given?

14. When was the second dose of vaccine given?

15. When was the third dose of vaccine given?

16. When was the fourth dose of vaccine given?

17. When was the fifth dose of vaccine given?

18. When was the sixth dose of vaccine given?

19. When was the seventh dose of vaccine given?

20. Did the patient have any pre-existing conditions at the time that the vaccine was given?

21. When did the adverse reaction begin?

22. Did the adverse reaction resolve?

23. If the adverse reaction resolved, when did this happen?

24. Is the adverse event getting worse?

25. What side effects were experienced?

26. What is the patient’s outcome?

27. How soon after the vaccine did the side effects occur?

28. Were any laboratory tests done?

29. How was the reaction treated?

Taking Back Our Rights, Freedoms and Liberties (TBORFAL)