Cowin Data Entry
Registration number / ID number of the beneficiary
*
Name of the person notifying the case
*
E-Mail
Contact phone number
*
Designation
Place of present posting
*
Date of notification (Submission date in Cowin)
*
Address of Session Site/Place of vaccination:
*
Date of vaccination
*
Time of vaccination
( hh:mm )
Beneficiary name
*
Date of birth
*
Age
*
Sex
*
Select
Male
Female
Spouse name / Father's name
Address
Name of vaccines administered to this case
*
Dose no.
*
Name of manufacturer
*
Batch/Lot No.
*
Date of manufacturing
*
Date of opening of vaccine vial
No. of OTHER beneficiaries who received vaccine from SAME vial in this session
Comorbidities
Adverse event(s) - clinical (TICK AS MANY AS APPLICABLE):
Within 30 minutes after vaccination
Anxiety reaction
Anaphylaxis / allergic reaction
Any Other
After 30 minutes of vaccination
Fever
Pain / redness / swelling at injection site
Abscess at injection site
Seizures
Sepsis
Any Other
Hospitalization
*
Select
Yes
No
Name of Hospital & Address
Death
Date of Death
Time of Death
Is this part of cluster?
*
Select
Yes
No
Date of first symptom
*
Time of first symptom
( hh:mm )
*
Current status of patient
*
Select
Recovered completely
Recovered with Sequalae
Still Under Treatment
Death
Unknown