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Rapid Reporting Form

Thank you for reporting your or your family member’s experience following vaccination.

SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community) is Victoria's vaccine safety surveillance service. We are are a public health partnership initiative of the Victorian Immunisation Program funded by the Department of Health (DH) Victoria.

What is an adverse event following immunisation (AEFI)?

An AEFI is any untoward event occurring after immunisation, and may be a result of the vaccination or occur by coincidence, ie, an event that would have happened even if no vaccination was given.

Only expected, common or non-serious adverse events can be reported through this SAEFVIC Rapid Reporting form:

At the injection site: pain, swelling.
Through the body: fever, chills, tiredness, headache, muscle aches.

If you have unexpected or serious AEFI not listed above, consider reporting through the extended reporting form and you may receive follow up by phone or email.

Time stamp

D-M-Y H:M

If you or the patient are experiencing the following call triple zero (000) immediately:

Central or crushing chest pain lasting over 10 minutes
Unconsciousness or a seizure (convulsions)
Severe difficulty breathing or turning blue
Severe bleeding or inability to control bleeding with pressure
Sudden inability to move or speak, or sudden facial drooping

Why do we collect information about your vaccination experience?

Timely reporting to SAEFVIC enables us to quickly detect any potential vaccine safety or system problems. This helps to ensure Victoria has a safe immunisation program and maintains community confidence.

What do we do with your report?

Combine it with the information from other reports and make the combined, de-identified information available as vaccine safety data for the general public (Victorian COVID-19 vaccine safety data) immunisation policy makers, national vaccine surveillance networks and researchers of ethically approved related studies.
Investigate any potential vaccine or immunisation system problems and notify the relevant government bodies.
Forward reports to the Therapeutic Good Administration (TGA) who closely monitor and assess vaccine safety in Australia
For any significant adverse events, your information may be provided to a clinician who will check in with you and may provide further assistance

We will not disclose personal information about you to anybody else, unless you have given consent, or we are authorised or required to do so by law.

Both the rapid and extended reports form part of the SAEFVIC clinical quality registry managed by MCRI. MCRI stores all personal information in secure environments and performs regular security testing of its systems. Please see the MCRI Privacy Policy for more information about how MCRI handles your personal information.

If you have any questions please contact us at enquiries@saefvic.org.au or visit our website.

Are you reporting for yourself or somebody else?

* must provide value

Myself

Somebody Else

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Reporter First Name

Reporter Surname

Patient First Name

Patient Surname

Patient DOB

* must provide value

D-M-Y

OR Age Range

Are you/your patient Aboriginal and/or Torres Strait Islander ?

Yes

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Patient Sex

* must provide value

Male

Female

Neither

Unknown

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Postcode

VACCINE ADMINISTRATION

When was the vaccination?

D-M-Y

Where was the vaccine administered?

Vaccination Venue:

Vaccine

* must provide value

COVID AstraZeneca

COVID Pfizer

COVID Moderna

COVID Novavax

COVID (brand unspecified)

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Specify

Was an Influenza vaccination (Flu) administered on the same day?

* must provide value

Yes

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Dose number

Unknown

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Is this a booster dose, or additional dose for immunocompromised?

Booster

Immunocompromised

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HOW LONG AFTER VACCINATION DID THE FIRST SYMPTOMS APPEAR?

Within 60 minutes

Within 24 hours

Within 7 days

Over 1 week

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REACTION DETAILS

Did you have any reactions following your most recent vaccination? Select all that apply

Only expected, common or non-serious side effects can be reported through this SAEFVIC Rapid Reporting form

Local injection site reaction

Pain

Redness

Swelling

Itching

General Symptoms

Fatigue

Fever

Chills

Nausea

Vomiting

If the FEVER is over 40 degrees celcius, or has lasted more than 3 days:

See a General Practioner (GP) within the next 24 hours

If the GP’s surgery is closed, contact an after hours doctor, or attend the nearest emergency department (ED).

Musculoskeletal

Headache

Muscle or body aches

Joint aches or pain

Muscle/Body pain location

abdominal

chest

If the HEADACHE or PAIN/SWELLING in joints or limbs is severe, for example prohibits you from carrying out basic activities like standing:

Go to the emergency department (ED)

Do not drive yourself. If you can’t get to an ED, or you’re worried that your symptoms change or gets worse before you go to the ED, call triple zero (000).

Yes

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If the HEADACHE persists beyond 72 hours (3 days):

See your General Practioner (GP) today

See a GP within the next 24 hours. If the GP’s practice is closed, follow their instructions for contacting an emergency doctor, or attend the nearest emergency department (ED)

Symptom Management

Did you do something after vaccination to relieve any of your symptoms?

Tick one or more boxes

Take Paracetamol / Ibuprofen

Call a helpline

See my GP

See a Nurse

Attend the ED

Other

If the adverse event was severe enough to warrant seeing a GP or nurse, or attend the ED, it is potentially unexpected or severe.

Consider reporting through the extended reporting form as described here, and you may receive follow up by phone or email.

Do you have other symptoms not listed above?

Yes

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If the adverse event was not listed in SAEFVIC Rapid, it is potentially unexpected or severe.

Consider reporting through the extended reporting form, and you may receive follow up by phone or email.

Consent status

Do you consent to have your side effects reported?

* must provide value

Full consent to report and contact

Consent to report, but NOT to contact

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Consent status

Does the patient consent to have their side effects reported?

* must provide value

Full consent to report AND contact

Consent to report, but NOT to contact

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Email Address

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Project Access Restricted

Rapid Reporting Form

What is an adverse event following immunisation (AEFI)?

You have selected an option that triggers this survey to end right now.