Incident Report for Suspected Vaccine Adverse Event

Patient Information
Age: Sex: Breed:

Pertinent History

Previous or Current Ailments:

Case Identification #:
(if previous report filed)

Adverse Event

Description of the Event:
(include onset of signs
following inoculation;
clinical signs-lesions)
Supporting Lab Data:
(include normal and abnormal
findings if applicable)
Date of Inoculation:
Date signs were first noticed:
Outcome:

Provide a list of all immunobiologic products administered (for combination
products, list the product code and serial number of each vial
as well as the product code of the combination package)

Product Brand Name:
Serial or Lot #:
Product Code #:
Dose:
Route of Administration:
Site:
Needle Size:
Date Reconstituted:

List all concurrent non-biologic drugs and dosages (i.e. heartworm preventative,
antiparasitic drugs, glucocorticosteroids, antibiotics, etc.)

  

Contact Information


Name, address, phone of Veterinarian

Name, address, phone of Owner-Agent