Case Data Entry

Case ID:
AEFI ID:

** The available information has been filled by reporting district. Please complete the form and submit.

Field marked * are mandatory fields.
* Please fill 'all' mandatory fields, In mandatory text fields where information is not available, please consult your DIO/MO or enter 'Information Not Available'.

Section A (To be submitted by MO within 24 hours of case notification to DIO)
Complete address of the case with landmarks (street name, house number, village, block, tehsil, pin no., telephone no.)
Name of vaccines received (write vaccine & diluent details in seperate rows)* Dose no. (zero/ first / second/ etc. as applicable)* Name of Manufacturer / Brand Name** 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

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(use separate form for each case in a cluster)
Section B: District immunization office to complete and forward to state and national level within 24 hours of receiving the above information
State Immunization Officer & Deputy Commissioner(UIP),
Immunization Division of Govt of India, MoHFW,
Nirman Bhawan, New Delhi - 110108.
Fax: 011-23062728 Email: aefiindia@gmail.com
Section C: National level to complete

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