AEFI CASE REPORTING FORM (CRF)

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'.

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Section A (To be submitted by MO within 24 hours of case notification to DIO)

State

District

Block/Ward:

Block Ward

Village/Urban Area

Village Urban Area

Block

Ward

Urban Area

Village

Name of reporting MO (person filling this form) *

Today's Date

Posted at *

Designation *

Time of preparing this form ( hh:mm )

Contact phone number *

E-Mail *

Date case visited and examined/interviewed

Notified by(name) *

Designation(please circle):*

health worker government doctor private practitioner community media Others(specify)

Date Notified to MO: *

Patient's name *

Sex *

Date of birth *

(If exact DOB is not available please consult Dio/Mo for approximate DOB)

Age (in years)

Age (in months)

Age (in days)

Mother's name *

Father's name *

Complete address of the case with landmarks (street name, house number, village, block, tehsil, pin no., telephone no.)

Address *

Pin No.

Phone

Date of vaccination *

Time of vaccination ( hh:mm ) *

Address of session site *

Session/Campaign/Other *

Session:

Routine (including Special Immunization Week) Other

Campaign:

(SIA)-IPPI MR JE Others(Specify)

Other:

Place of vaccination:*

govt health facility outreach private health facility others

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			Date of opening of vial	Time of opening the vial (for reconstituted vaccine)	No. of OTHER beneficiaries who received vaccine from the SAME vial in this session

Any other vaccine:

Date of first symptom *

Time of first symptom ( hh:mm ) *

Hospitalization*

Date of hospitalization

Time of hospitalization ( hh:mm )

Name of hospital (if hospitalized)

Address of hospital (if hospitalized)

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Scanned CRF Documents

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Supporting Documents

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Case Reporting Form | Download Report

Report

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Case Data Entry

Case ID: Case ID

AEFI CASE REPORTING FORM (CRF)

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Upload scan of original Case reporting form

Upload any other supporting document

Case Reporting Form | Download Report