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VAERS

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What adverse vaccine events are health care providers required to report?

The Vaccine Adverse Event Reporting System (VAERS), operated by the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), should be notified of any adverse event by completing a VAERS reporting form. The VAERS form may be obtained by calling 1-800-822-7967 or from the VAERS Web site.

The following events are required to be reported:

1. Any event set forth in the Vaccine Injury Table (list.asp) that occurs within the time period specified or within 7 days, if that is longer.
2. Any contraindicating event listed in the manufacturer’s package insert. In addition, VAERS accepts all reports by any interested party of real or suspected adverse events occurring after the administration of any vaccine.

Please note: Submitting a reporting form to VAERS is not the same as filing a claim under the VICP as they are two separate programs.

What if you suffer a side effect from the vaccine?
You may be eligible to bring a claim under the National Vaccine Injury Compensation Program. Learn more here.

Do I Qualify for the National Vaccine Compensation Program? PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:
City:
State:	-Please Select- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:
Phone:	() - ext.
INJURED PERSON INFORMATION
Date of Birth:	MM January February March April May June July August September October November December DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902
For whom are you inquiring about?	PLEASE SELECT Minor Self Other
If you are NOT inquiring on your own behalf, what is your relationship?
Is the person deceased?	Yes No
If deceased, the cause of death as stated on the death certificate:
Date of Death:	MM January February March April May June July August September October November December DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902
Was there an autopsy performed?	Yes No
INJURY INFORMATION
Has person had any of the following injuries within 48 hours of recieving the vaccination:
Encephalopathy Stroke Heart Attack Brain Injury Death Seizure Guillian-Barre Syndrome
DRUG INFORMATION
Has person had any of the following vaccinations:
Tetanus Pertussis Measles Mumps Chicken Pox (Varicella) MMR Rubella Polio Hepatitis B Rotavirus (Rotashield) Flu Shot DTaP DPT
Other:
Dates that Vaccine(s) were given?
Did behavior regress after receiving vaccines?	Yes No
If yes, please describe regressive behavior:
Other Information: