Complete vaccine administration form

Best Doctor / Health Care Professional Information section

When a case contains multiple vaccines, for each individual vaccine you can enter the following specific details in the Vaccine Administration, Vaccine Facility and Best Doctor / Health Care Professional Information sections:

  • Person completing Form Relation to Patient
  • Title
  • First Name
  • Middle Name
  • Last Name
  • Phone
  • Email

Vaccine Facility section:

  • Facility Name
  • Address 1
  • Address 2
  • City
  • State
  • Country
  • Postal Code
  • Phone
  • Fax
  • Facility Type
  • Facility Military Flag

VAERS Form-1 Use Only section:

  • Administered By
  • Resp. Physician
  • County
  • State
  • CDC/FDA VAERS #
  • Purchased With
  • Illness at Time of Vaccination
  • Reported Previously
  • Required ER Visit

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