AEFI 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
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