Causality Assessment Report

(Office of state Immunization officer)

(State AEFI committee to complete causality assessment exercise and forward this report to
GoI within 30 days of receipt of final CIF at the state)
Section A (Preparation of causality assessment)
Date of receipt of Final CIF from district at state D D M M Y Y Y Y

Patient Name

Date of Birth

Age (in months) Sex Male Female

Complete residential address of the case with landmarks (Street name, house number ,village, block, PIN No etc

Pin Phone

Checklist for state EPI officer

S.No List of document copies received Availability Remarks (If any)

1 Case Report form ( CFR) Yes/No

2 Preliminary Case investigation form Yes/No

3 Postmortem report (in case of death) Yes/No

4 Verbal autopsy form (in case of sudden unexplained death) Yes/No

5 Any pathology / microbiology test report Yes/No

5A. Blood test report Yes/No

5B. CSF report Yes/No

5C Urine test report Yes/No

6. Doctor’s prescription /treatment record for AEFI Yes/No

7. Doctor’s prescription /treatment record for other illness Yes/No

8 Laboratory result of vaccine (if sent for testing) Yes/No

9 Laboratory result of syringes /Other drugs (if sent for testing) Yes/No

10 Any other document relevant to case Yes/No

 Causality Assessment Summary
STATE DISTRICT NATIONAL ID

Step 1 (Eligibility)
Name Of the Patient Name of one or more What is the valid Does the diagnosis meet
vaccines administered Diagnosis? a case definition?
before this event

 Create your Question on causality here (There can be more than one research Questions)
(The event for review in step 2)

Has the ………………………………………………..Vaccine/Vaccination caused

……………………………………………………………….?

Has the ………………………..…………………. Vaccine/Vaccination caused

…………….……………………………………………….?

 In case a clinical diagnosis not available sysmptoms may be used

State District NATIONAL ID
 Step (Algorithm) Review all steps ans (√) in all appropriate box

IA. IIIA.
Inconsist Inconsiste

I.Is II.Is there III.Is IV.

there a known there a Review Y
Y
e
e
s
s Is IV
II
(Time).Wa

IIA. IVA. IV B. IV C.
Consiste Consist Consist
Y Inter
e N
s o

Y
Y e
e s
s

Notes for Step 3:

Level of Certainty as per Brighton’s Classification (with reason for the same)

Feedback on the case for District/State /others (specify):

D
.
Tick Reason for Unclassifiable:
1. Supporting documents (Hospital Records/ Post
Mortem- Histopathology, Chemical analysis/

Level of Certainty as per Brighton’s Classification (with reason for the same)

B1.This is a Potential signal may be considered for investigation

Summarize the classification logic:

With available evidence. We could conclude that
the classification is…………………… because:

Feedback on the case for District/State / Others (specify):

Details of state AEFI committee members who conducted the causality assessment
Serial Name of Experts Signature Date
No
1
2

Date of review Date of submission

of this case of report to GoI

State nodal Person (Officer forwarding this Report)

Name……………………… Designation ……………………………. Date of submission to national level …………………………………

Mobile No………………………….. Landline (with STD code)…………………………………….……… Fax No………………………………….

Email id…………………………………………….. Complete Office address (with Pin code)………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………………………………………………………………………

Signature/Seal……………………………. Date…………………………………

Please ensure that this causality assessment report reaches:

Deputy Commissioner,
Immunization Division of Govt of India, MoHFW, Nirman Bhawan,
New Delhi- 110108
(Fax : 011 23062728 email: aefiindia@gmail.com)

Section B For use at national level

(Office of Deputy Commissioner-UIP)
Date of receipt of final CIF from district at
national level
Date of receipt of causality assessment from
state