Adverse Event Reporting Form

Name

First NameLast Name

Birth Date

MonthDayYear

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

State

Gender

Blood type

Select the vaccine brands you received

How many COVID-19 vaccine doses did you receive?

Date of 1st Dose

MonthDayYear

Date of 2nd Dose

MonthDayYear

Date of 3rd Dose

MonthDayYear

Date of 4th Dose

MonthDayYear

Date of adverse reaction

MonthDayYear

Please select the symptoms and diagnosis

What treatment did you receive?

Please describe offered/prescribed medication and treatment

Which were the official reporting of the adverse reaction?

What were your motivations for being vaccinated?

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

Attitude to COVID-19 vaccination

Further questions and comments