UWIN Form

To make changes, select the 'Edit Form' button. After updating the information, click 'Update'/'Submit' to save your changes.

State

District

Subdistrict

Health facility

Registration number / ID (as generated by U-WIN) *

Designation/user level *

Name *

Mobile number *

Name of the person notifying the case *

Contact phone number *

E-Mail

Place of present posting *

Address of notifier

Designation*

Address of session site*

Type of Session Site*

Sub-type (rural/urban)*

Category*

Source of vaccine

Date of vaccination *

Time of vaccination ( hh:mm ) *

Vaccination done in*

Patient Name*

Sex

DOB

Age

Date of birth*

Age (in years)*

Age (in months)*

Age (in days)*

Mother’s name

Guardian’s Name*

Complete Address with landmarks*

Mobile number*

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) *

Pregnancy / child birth related events *

Death of mother

Abortion

Early delivery

Child dead at birth

Child death within 28 days after birth

Birth defect in newborn

Date of first symptom *

Time of first symptom ( hh:mm ) *

Whether hospitalized?*

If hospitalized, date of hospitalization *

If yes, name of hospital

Time of hospitalization

If hospitalized, outcome?

Whether death?*

If death, date of death*

Time of death ( hh:mm )

Current status of patient:*

Is this case part of a cluster (Were similar events reported in other vaccine recipients from the same session or same area around the same time as this case?)*

Past Vaccination Details

UWIN Form

AEFI ID :