Reporter Name | Zhang San | Tel. of Reporter |
| Report Date |
|
Patient Name | Li Si | Gender of Patient | Male | Tel. of Patient |
|
Birthday of Patient | Date | Primary Disease | Hypertension | Date of ADR Occurrence |
|
Suspect Vaccine | Vaccine Name | Manufacturer | Lot No. | Vaccination Date | Organized Vaccination Mode |
xx Vaccine | xx Company | 20190506 | Date | Routine | |
Number of Vaccinated Doses | Vaccinated Dosage (mL) | Vaccination Route | Vaccinated Position | Vaccination Site | |
1 | 0.5 | Intramuscular injection | Deltoid muscle of left upper arm | XX County, XX City, XX Province | |
Concomitant Medication (if any) | Vaccine Name | Manufacturer | Lot No. | Vaccination Date | Organized Vaccination Mode |
xx Vaccine | xx Company | 20190406 | Date | Routine | |
Number of Vaccinated Doses | Vaccinated Dosage (mL) | Vaccination Route | Vaccinated Position | Vaccination Site | |
1 | 0.5 | Intramuscular injection | Deltoid muscle of right upper arm | XX County, XX City, XX Province | |
Description & Treatment of Adverse Reaction (including symptoms, signs, clinical tests, etc.) | Itching, redness, swelling and induration appeared at the vaccination position after the xx vaccination on XX (date), and the patient went to the hospital for xx treatment on XX (date). | Whether hospitalized | No | ||
Results of adverse reactions (please fill in “Cured”, “Improved”, “Sequelae”, “Death” or “Unknown”) | Improved | ||||
Remarks | Reporters may send documents containing this form to adr@olymvax.com or call 400-9687-119 to report directly. For any questions during reporting, please call this number for consultation. | ||||