Healthcare Practitioner’s Vaccine Error Reporting Form

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Complete

Use the form below to report an error or hazard to the ISMP National Vaccine Errors Reporting Program

If you want to report a non-preventable adverse reaction to a vaccine product, please visit the US Department of Health and Human Services Vaccine Adverse Event Reporting System (VAERS) (http://vaers.hhs.gov).

Report submission type

Error occurred and reached the patient

Error occurred but did NOT reach the patient

Hazardous condition (no error, but situation warrants concern)

Please indicate the approximate date of the error or event or discovery of the medication safety concern

Vaccine(s) involved in this event

Search by

Brand name

Generic name

Vaccine abbreviation

Generic name

Vaccine abbreviation

Dosage (optional)

Lot # (optional)

Expiration date (optional)

NDC (optional)

Vaccines included in this report

Brand name	Generic name	Manufacturer	Operations
Brand name	Generic name	Manufacturer		Expiration date

'Remove' will remove all of the added vaccines.