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VAERS Checklist of Information Needed Cheat Sheet (DRAFT) by [deleted]

Gather this information before logging on to report

This is a draft cheat sheet. It is a work in progress and is not finished yet.


The Vaccine Adverse Event Reporting System (VAERS) accepts all reports, including reports of vaccin­ation errors. Guidance on reporting vaccin­ation errors is available if you have additional questions.

The following is a list of the inform­ation that will be needed to complete the Online Submission form.

Patient Info Who Received Vaccine

O Name, address, phone number and email address
O Date of birth
O Sex (male or female)
O Date and time of vaccin­ation
O Date and time the adverse event (health problem) started
O Age at vaccin­ation
O Whether the patient was pregnant at the time of vaccin­ation and the due date
O Prescr­ipt­ions, over-t­he-­counter medica­tions, dietary supple­ments and herbal remedies being taken
O Allergies to medica­tions, food, or other products
O Other illness es at the time of vaccin­ation ( and up to one month prior)
O Chronic or long- standing health conditions

Person Completing the VAERS Form

O Name, address, phone number and email address
O Relation to the patient (for example: healthcare profes­sional, parent, caregiver, etc.)

Healthcare Profes­sional Inform­ation

O Name and phone number for the best doctor or healthcare profes­sional to contact to get more inform­ation about the patient and the adverse event Inform­ation about the facility (or place) where the vaccine was given
O Facili­ty/­clinic name, fax number, address and phone number
O Facility type (for example: doctor’s office or hospital, pharmacy or drug store, workplace clinic, etc.)


Vaccines Given and What Happened

O Vaccine type and brand name, manufa­cturer , and lot number
O How the vaccine was given (route of admini­str­ation, body site where given, and dose number if the vaccine was part of a series)
O Descri­ption of the adverse event, including medical treatment and diagnosis
O Results of medical tests and lab oratory tests
O Outcome of the adverse event (for example: doctor office visit, emergency room visit, hospit­ali­zation, etc.)
O Whether the patient has recovered from the adverse event

Additional Inform­ation

O Any other vaccines received by the patient within a month prior to the current vaccine(s)
(include vaccine type and brand name, manufa­cturer , lot number, and how the vaccine was given)
O Adverse event (s) after previous vaccin­ations
O Patient’s race and ethnicity