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Barbados Drug Service

druginfo@drugservice.gov.bb

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

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

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SELF REPORTING OF EVENTS FOLLOWING VACCINATION

For Patients

Case ID

You will be provided with a Case ID upon submission.

Details of person vaccinated

Full Name

Sex

Telephone Numbers(s)

Details of vaccination

All required information is located on your vaccination card.

Date and time of vaccination

Date Picker

Is this your first or second dose?

Describe the side-effect(s) after receiving the vaccine

Date of first side-effect(s)

Date Picker

Other information

Did you seek medical help?

When filling out this form