Notification Of Post-vaccination Adverse Reactions (11 Aug 04)
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NOTIFICATION OF POST-VACCINATION ADVERSE REACTIONS PARTICULARS OF PERSON IMMUNISED Birth Certificate or NRIC No.
Name (in BLOCK LETTERS)
Sex
Ethnic Group
Date of Birth Day
Male
Mth
Yr
Female
Residential Status
Chinese
Indian
Singapore citizen/Permanent resident
Malay
Other
Non-Resident
Address
PARTICULARS OF IMMUNISATION [Tick (3) appropriate box] Type of immunisation BCG
Poliomyelitis Oral
Chickenpox
Hepatitis A (HAV)
Poliomyelitis Inactivated Vaccine
Influenza
Hepatitis B (HBV)
Measles
Japanese encephalitis
Hepatitis A & B
Measles/Mumps/Rubella
Meningococcal meningitis
Diphtheria/Tetanus
Mumps/Rubella
Pneumococcal disease
Diphtheria/Pertussis/Tetanus
Mumps
Rabies
Diphtheria/Tetanus/acellular Pertussis (DTPa)
Rubella
Typhoid injection
DTPa + IPV
Haemophilus influenza type B (HiB)
Typhoid Oral
DTPa + HiB
HiB + HBV + Meningococcal meningitis
Tetanus Toxoid
DTPa + HiB + IPV
HiB + Meningococcal meningitis
Yellow Fever
DTPa + HiB + IPV + HBV
Cholera Oral
Others (specify) _______________ 1st dose
Date given Day
Mth
Yr
2nd dose
3rd dose
Primary course Booster
Place of vaccination
PARTICULARS OF VACCINE ADMINISTERED Batch No.
Name of vaccine manufacturer
PARTICULARS OF ADVERSE POST-VACCINATION REACTIONS Date of onset of symptoms Day
Mth
Name of hospital admitted, if relevant
If died, date of death
Yr
Day
Mth
Yr
Type of reactions Anaphylaxis
Convulsion
Paralysis
Hyporesponsiveness
Encephalopathy/Encephalitis
Others* (specify) _______________________________
* For example, screaming attacks, abscess formation. Please note that minor reactions e.g. fever, local redness need not be reported. Brief clinical features including progress and final outcome
PARTICULARS OF PRACTITIONER REPORTING ADVERSE REACTIONS Name of Medical Practitioner (BLOCK LETTERS)
Signature
Name and Address of clinic/hospital
Date
Please forward the completed Notification to the Communicable Diseases Division, Ministry of Health through fax at Fax No. 62215528/38 or through mail to Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854.
Name (in BLOCK LETTERS)
Sex
Ethnic Group
Date of Birth Day
Male
Mth
Yr
Female
Residential Status
Chinese
Indian
Singapore citizen/Permanent resident
Malay
Other
Non-Resident
Address
PARTICULARS OF IMMUNISATION [Tick (3) appropriate box] Type of immunisation BCG
Poliomyelitis Oral
Chickenpox
Hepatitis A (HAV)
Poliomyelitis Inactivated Vaccine
Influenza
Hepatitis B (HBV)
Measles
Japanese encephalitis
Hepatitis A & B
Measles/Mumps/Rubella
Meningococcal meningitis
Diphtheria/Tetanus
Mumps/Rubella
Pneumococcal disease
Diphtheria/Pertussis/Tetanus
Mumps
Rabies
Diphtheria/Tetanus/acellular Pertussis (DTPa)
Rubella
Typhoid injection
DTPa + IPV
Haemophilus influenza type B (HiB)
Typhoid Oral
DTPa + HiB
HiB + HBV + Meningococcal meningitis
Tetanus Toxoid
DTPa + HiB + IPV
HiB + Meningococcal meningitis
Yellow Fever
DTPa + HiB + IPV + HBV
Cholera Oral
Others (specify) _______________ 1st dose
Date given Day
Mth
Yr
2nd dose
3rd dose
Primary course Booster
Place of vaccination
PARTICULARS OF VACCINE ADMINISTERED Batch No.
Name of vaccine manufacturer
PARTICULARS OF ADVERSE POST-VACCINATION REACTIONS Date of onset of symptoms Day
Mth
Name of hospital admitted, if relevant
If died, date of death
Yr
Day
Mth
Yr
Type of reactions Anaphylaxis
Convulsion
Paralysis
Hyporesponsiveness
Encephalopathy/Encephalitis
Others* (specify) _______________________________
* For example, screaming attacks, abscess formation. Please note that minor reactions e.g. fever, local redness need not be reported. Brief clinical features including progress and final outcome
PARTICULARS OF PRACTITIONER REPORTING ADVERSE REACTIONS Name of Medical Practitioner (BLOCK LETTERS)
Signature
Name and Address of clinic/hospital
Date
Please forward the completed Notification to the Communicable Diseases Division, Ministry of Health through fax at Fax No. 62215528/38 or through mail to Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854.
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