Complete vaccine administration form

The following are the fields for VAERS Form-1 Use Only:

Field or Control Name	Description
Resp. Physician	Enter the name of the physician responsible for the patient.
County	Enter the county where the patient was vaccinated.
State	Enter the state where the patient was vaccinated.
CDC/FDA VAERS #	Enter the verification number.
Purchased With	Select an item from the list to describe how the vaccine was purchased.

The following are the fields for Vaccine Facility Information

Field or Control Name	Description
Facility Name	Enter the name of the facility where the vaccine was administered.
Country	Enter the country of the facility where the responsible physician works.
Facility Type	Enter the facility type where the patient was vaccinated.
Facility Military Flag	Indicates whether or not the vaccination facility was a Military facility.