Barbados Drug Service

druginfo@drugservice.gov.bb

Level 6 & 7, Warrens Towers II, Warrens, St. Michael

(246) 535-4300 / (246) 535-4322

SELF REPORTING OF EVENTS FOLLOWING VACCINATION

For Patients

By continuing I agree that I am willing to complete a digital version of the document.

For Health Professionals

Please click here for COVID19 Active Surveillance Form

Case ID

You will be provided with a Case ID upon submission.

Details of person vaccinated

Address

National Registration Number or Passport Number (Non-nationals)

Age

Sex

Male

Female

Other

Telephone Numbers(s)

Home

Mobile

All required information is located on your vaccination card.

Vaccine Name

Batch Number

Date and time of vaccination

Place of vaccination

This is the:

First dose

Second dose

Third dose

Fourth dose

Other (specify)

Date of first side-effect(s)

Did you seek medical help?

Yes

Provide details

List other medical condition you may have

List other medication being taken at the same

When filling out this form

Side-effect(s) resolved

Side-effect(s) persist