Case Data Entry

Case ID: AEFI ID:

State Causality Assessment Report(STATE CA REPORT)

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'.

Page 1

Section A

Name of Patient *

Name of one or more vaccines administered before this event *

What is the Valid Diagnosis?*

Does the diagnosis meet a case definition?*

Step 4 (Classification)*

A.Consistent causal association to immunization

A1. Vaccine product-related reaction (As per published literature ) A2. Vaccine quality defect-related reaction A3. Imminization error-related reaction A4. Immunization anxietyrelated reaction

B. Indeterminate

*B1. Temporary relationship is consistent but there is insufficient definitive evidence for vaccine causing event (may be new vaccine-linked event) B2. Qualifying factors result in conflicting trends of consistency and inconstistency with causal association to immunization.

C. Inconsistent causal association to immunization

C. Coincidental
Underlying or emerging condition(s), or condition(s) caused by exposure to something other than vaccine

D. Unclassifiable
Specify the additional information required for classification

Date of review of this case *

Details of state AEFI committee members who conducted the causality assessment

Sr No.	Name *	Designation*	Phone#*	Signature
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State nodal person (officer forwarding this report)

Name

Date of submission to national level

Designation

Mobile No

Landline (with STD code)

Fax No.

Email id

Complete office address (with Pin code)

Please ensure that this causality assessment report reaches:

Deputy Commissioner,
Immunization Division of Govt of India, MoHFW,
Nirman Bhawan, New Delhi - 110108.
Fax: 011-23062728 Email: aefiindia@gmail.com

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