Use this form to report any AEFI caused by any kind of vaccination in Zanzibar
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Step 5

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Step 6

Reporter Information
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# Health facility
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Add Patient Information
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# Other Information
Adverse Event(s)
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Vaccination Information
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# Name Batch number Dosage Date started Expire date
No Content Added!
Diluent If Applicable
# Name of Diluent Batch / Lot Number Reconstitution_date Expire date
No Content Added!
Case Outcome
Do you consider the reaction to be serious
No Yes
Autopsy done ?
No Yes Unknown
Outcome:
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