Walvax沃森生物

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Report of Adverse Events Following Immunization (AEFI)

Name of Vaccine Recipient
Date of Birth
Gender
Country
Vaccination Institution
Vaccine Name
Lot No
Co-administration
For co-administration, please fill in the name and manufacturer of the vaccine
Manufacturer
Date of Vaccination
Date of Adverse Event Onset
Symptom
Reported by
Relationship to Vaccine Recipient
Contact Person
Address
E-mail
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