The form reproduced here is a newly revised version of the national vaccine-associated adverse event reporting form. Provinces may have different versions, or may use this form with their own logo and address. It is important to contact local health departments to verify their method of reporting. Report only events which cannot be attributed to co-existing conditions. Intervals, the time between vaccine administration and the occurrence of the adverse event, are to be stated after EACH event.
Space is given for concomitant medications and medical history.