Adverse events following immunization (AEFI) reporting form

On this page

• Who can submit an AEFI report
• When to report events
• Download form
• Instructions for filling out form
• Submitting a report

Who can submit an AEFI report

General public

If you are a vaccine recipient who has been vaccinated and have experienced an AEFI, please ask your doctor, nurse practitioner, nurse, or pharmacist to complete an AEFI form on your behalf.

Learn more:

• Vaccine safety and possible side effects

Health care professionals

If a patient experiences an AEFI, please complete the appropriate AEFI form.

Submit an AEFI report to a province, territory or government department

When to report events

Report events which have a temporal association with a vaccine and which cannot be clearly attributed to other causes.

A causal relationship does not need to be proven, and submitting a report does not imply causality.

Of particular interest are those AEFIs which:

• meet one or more of the seriousness criteria
• are unexpected regardless of seriousness

Download form

Download the reporting form PDF for adverse events following immunization (1.0 MB, 7 pages)

Instructions for filling out form

The numbers below correspond to the numbered sections of the form.

All dates should be captured in ISO 8601 format: yyyy/mm/dd.

When reporting an AEFI, check one of the boxes on the top right-hand corner of the first page of the AEFI form to indicate whether it is an initial or follow-up report. For all follow-up reports, please specify the Unique episode number.

1a) The Unique episode number is assigned by the province/territory. Leave it blank unless authorized otherwise.

1b) The Region number is a number that corresponds to a given health unit. Leave it blank if it doesn't apply to your region.

2) The Pediatric surveillance reference number is automatically assigned by the active pediatric hospital surveillance network's system when an AEFI report is generated from one of their hospitals. Please leave this section blank if it does not apply to you. Provinces and territories should retain the assigned pediatric surveillance reference numbers when forwarding their reports to the Public Health Agency of Canada.

3) The information captured in this section is confidential and is intended for use only by the regional and/or provincial/territorial health officials.

4a) Indicate the province/territory where the vaccine was administered. Abbreviations may be used. Gender (indicate which gender identity the patient self-identifies as): Woman/Girl; Trans woman; Man/Boy; Trans man; Non-binary; Or please specify this patient's gender; Unknown; Not asked. Race (indicate which race category the patient best describes themselves): Black; East/Southeast Asian; Indigenous; Latino; Middle Eastern; South Asian; White; Another race category; Prefer not to answer; Do not know; Not asked. Indigenous status (indicate which Indigenous identity the patient self-identifies as): First Nations; Métis; Inuk/Inuit; Other Indigenous; Prefer not to answer; Not asked.

4b) Provide all information as requested in the table. For the "Dose number", provide the number in series (1, 2, 3, 4, 5, etc., or booster) if known. For the influenza vaccine, unless a patient receives 2 doses in one season, the "Dose number" should be recorded as "1".

7a) Indicate the highest impact of the AEFI on the patient's daily activities as assessed by the patient or the parent/caregiver.

7c) Provide details of any investigations or treatments in section 10. If the patient was already in hospital when immunized and the immunization resulted in a longer hospital stay, indicate "Resulted in prolongation of existing hospitalization" and provide the number of days by which the patient's hospital stay was prolonged. For all hospitalizations, indicate the date of admission and discharge.

8) MD: Medical Doctor, RN: Registered Nurse.

9) Choose, from section 9 (AEFI details), the description that best fits the AEFI being reported. Make sure to record the time to onset and duration of signs/symptoms using the most appropriate time unit: days (d), hours (h) or minutes (m). Time to onset: from immunization to onset of first sign/symptom. Duration: from onset of first sign/symptom to resolution of all signs/symptoms. Provide additional details of any investigation, therapy, and other information as appropriate in section 10.

10) All information that is pertinent to the AEFI but that has not been fully captured elsewhere or that needs further explanation should be recorded in this section. Document all known details of any investigations or treatments for the recorded AEFI.

11) This section is to be completed by the MOH/MHO (Medical Officer of Health), MD, RN or their designate who are assigned to provide public health recommendations according to the province/territory best practices.

12) Information in this section is not collected by all provinces/territories.

For additional information, please see the background information in the user guide:

• Reporting Adverse Events Following Immunization (AEFI) in Canada: User guide to completion and submission of the AEFI reports

Submitting a report

If filling out the Public Health Agency of Canada AEFI reporting form, return completed forms to your local public health unit.

The following provinces have their own form to fill out:

• Alberta
• British Columbia
• Manitoba
• New Brunswick
• Ontario
• Quebec

Access federal, provincial and territorial AEFI forms and contact information

Related links

• Data reports and publications for AEFIs
• Report a side effect of a health product, drug or medical device
• Canadian Adverse Events Following Immunization Surveillance System (CAEFISS)
• Vaccine safety: Resources for health professionals on surveillance, reporting and regulation