NOTIFICATION OF POST-VACCINATION ADVERSE REACTIONS

PARTICULARS OF PERSON IMMUNISED

Name (in BLOCK LETTERS) Birth Certificate or NRIC No.

Sex Date of Birth Ethnic Group Residential Status

Day Mth Yr
Male Chinese Indian Singapore citizen/Permanent resident

Female 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) _______________

Date given 1st dose 2nd dose 3rd dose

Day Mth Yr Primary course

Booster

Place of vaccination

PARTICULARS OF VACCINE ADMINISTERED

Name of vaccine manufacturer Batch No.

PARTICULARS OF ADVERSE POST-VACCINATION REACTIONS

Date of onset of symptoms Name of hospital admitted, if relevant If died, date of death
Day Mth 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.