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. |
Parent topic: Enter vaccine information