CASE REPORTING FORM (CRF) FOR ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI)

EPID Number: S O A - - - - Received on

Level Signature
Country - Province - District - Year - Case no (date)
District
Province
All fields in this form are mandatory
National EPI
National SAHPRA
*Compulsory field
(For Office use only)

SECTION A: IDENTIFYING INFORMATION

*Patient name and surname: *Reporter’s name and surname:
____________________________________________________ _________________________________________________

*Patient’s residential address: ___________________________ Designation/Position: _______________________________

____________________________________________________ Institution: ________________________________________

____________________________________________________ Telephone: ________________________________________

Caregiver’s name and surname: __________________________ *Mobile no: _______________________________________

Telephone: __________________________________________ *E-mail: __________________________________________

Please tick ( ) the appropriate box Date patient notified event to health system (DD/MM/YYYY):

Gender: M F Term: Full term Premature __ __/__ __/__ __ __ __

*Date of birth (DD/MM/YYYY): __ __/__ __/__ __ __ __ Today’s date (DD/MM/YYYY): __ __/__ __/__ __ __ __

Age at onset: Years Months Days

SECTION B: VACCINE INFORMATION (Please attach a copy of the Road to Heath Booklet (RTHB))

Health facility (or vaccination center) name: _____________________________________________________________

Vaccine/s administered Diluent
(Complete this section only for alleged vaccines /vaccines that were administered before the event) (Where applicable)
Dose *VVM
*Batch/ *Batch/
*Vaccines given *Date of *Time of number Stage Expiry Date and time of
Lot Expiry date *Manufacturer Lot
(Use trade names) vaccination vaccination (e.g. 1st, (If date reconstitution
number number
2nd, 3rd) applies)

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Patient name & surname: ________________________________ EPID Number: _____________________________

SECTION C: TRIGGER EVENTS

Date & time AEFI started: (DD/MM/YYYY) __ __/__ __/__ __ __ __ Hr Min
*Adverse event (s): (Tick () all boxes that apply)
Minor reactions Severe local reactions Systemic reactions
Swelling <5cm Pain, redness and/or swelling of Hospitalization
Redness more than 3 days duration Death
Rash Swelling >5cm Anaphylaxis
Excessive crying Swelling beyond nearest joint Fever ≥38°C
Fever <38°C Lymphadenitis Encephalopathy
Other (specify): Abscess Collapse / shock-like state
___________________________________ Other (specify): Seizures Febrile Afebrile
___________________________________ ___________________________________ Intussusception
___________________________________ ___________________________________ Diarrhoea
___________________________________ Vomiting
Toxic shock syndrome
Thrombocytopenia
Sepsis
Other (specify): __________________

_______________________________

Severe or Serious Adverse Event: Immediately Notify District Office for Case Investigation

Brief narrative of caregiver/client complaint (Use additional sheet if needed):

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Were there any other similar AEFIs reported in the facility in the past 30 days? Yes No (If yes, specify)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

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Patient name & surname: ________________________________ EPID Number: _____________________________

SECTION D: PREVIOUS HISTORY

*History of previous reactions to immunisation/treatment:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

SECTION E: PRELIMINARY ASSESSMENT AND ACTIONS AT THE TIME OF REPORT

(Tick () boxes that apply)

*Is this event a serious AEFI? Yes No

If Yes, tick ( ) in the appropriate box below

Death  Date of death (DD/MM/YYYY): __ __ / __ __ / __ __ __ __  Autopsy: Yes No Unknown

Hospitalisation  Date of admission (DD/MM/YYYY): __ __ / __ __ / __ __ __ __

 Name of hospital: __________________________ Hospital number: ______________________

Disability

Life threatening

Congenital anomaly

SECTION F (If applicable): WHAT WAS THE OUTCOME OF THE CASE FOLLOWING THE SUSPECTED AEFI?
(Tick () boxes that apply)

Recovering

Recovered fully (no complications)

Recovered with sequelae Specify: _________________________________________________________________

Not Recovered

Died

Unknown

SECTION G: FIRST DECISION MAKING LEVEL TO COMPLETE

Case investigation needed: Yes No If yes, date notified (DD/MM/YYYY):
__ __ / __ __ / __ __ __ __
District Office notified: Yes No
Date investigation planned (DD/MM/YYYY):
__ __ / __ __ / __ __ __ __

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