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State

District

Block *

Name of the healthcare facility/Planning unit (Medical College/Hospital/Nursing home/Clinic/CHC/PHC/Sub-center) *

Name of the person notifying the case *

Contact phone number *

E-Mail

Designation

Place of present posting *

Date of notification (Date of submission into software) *

Date of vaccination *

Time of vaccination ( hh:mm ) *

Address of session site / place of vaccination

Vaccination In:

Routine Campaign Other

Vaccine supplied by

Govt Pvt

Beneficiary name*

Sex *

DOB

Age

Date of birth

Age (in years)

Age (in months)

Age (in days)

Contact number

Address

Spouse name/Father's name

Name of vaccines received (write vaccine & diluent details in seperate rows)*	Dose no. (zero/ first / second/ etc. as applicable)	Name of manufacturer*	Batch/Lot No.*	Expiry date Month Year		Mfg date	Date of opening of vial	Time of opening vaccine vial / vaccine reconstitution	No. of OTHER beneficiaries who received vaccine from the SAME vial in this session

Any other vaccine:

Adverse event(s) (TICK AS MANY AS APPLICABLE) *

Hospitalization

Name & Address of hospital (if hospitalized)

Death

If died, date of death

Time of death ( hh:mm )

Date of onset of first symptom *

Time of onset of first symptom ( hh:mm ) *

Is this case a part of cluster

Current status of patient: