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Submission: On July 24 via manual from US — Scanned from DE
Submission: On July 24 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET /search/node
<form action="/search/node" method="get" id="search-block-form" accept-charset="UTF-8" data-once="form-updated" data-drupal-form-fields="edit-keys">
<div class="form-item js-form-item form-type-search js-form-type-search form-item-keys js-form-item-keys form-no-label form-group">
<div class="input-group"><input title="Enter the terms you wish to search for." data-drupal-selector="edit-keys" class="form-search form-control" placeholder="Search ISMP" type="search" id="edit-keys" name="keys" value="" size="15"
maxlength="128"><span class="input-group-btn"><button type="submit" value="Search" class="button js-form-submit form-submit btn-primary btn icon-only"><span class="sr-only">Search</span><span class="icon glyphicon glyphicon-search"
aria-hidden="true"></span></button></span></div>
<div id="edit-keys--description" class="description help-block"> Enter the terms you wish to search for. </div>
</div>
<div class="form-actions form-group js-form-wrapper form-wrapper" data-drupal-selector="edit-actions" id="edit-actions--2"></div>
</form>POST /antibot
<form class="webform-submission-form webform-submission-add-form webform-submission-verp-form-form webform-submission-verp-form-add-form js-webform-disable-autosubmit js-webform-details-toggle webform-details-toggle antibot"
data-drupal-selector="webform-submission-verp-form-add-form" enctype="multipart/form-data" data-action="/form/verp-form" action="/antibot" method="post" id="webform-submission-verp-form-add-form" accept-charset="UTF-8" data-once="form-updated"
data-drupal-form-fields="edit-pso,edit-report-submission-type-error-occurred-and-reached-the-patient,edit-report-submission-type-error-occurred-but-did-not-reach-the-patient,edit-report-submission-type-hazardous-condition-no-error-but-situation-warrants-concern,edit-date-of-event-error,edit-search-by-brand-name,edit-search-by-generic-name,edit-search-by-vaccine-abbreviation,edit-generic-name,edit-abbreviated-name,edit-brand-name,edit-dosage,edit-lot,edit-expiration-date,edit-ndc,edit-add-vaccine,edit-vaccines-items-0-brand-name,edit-vaccines-items-0-generic-name,edit-vaccines-items-0-manufacturer,edit-vaccines-items-0-operations-add,edit-vaccines-items-0-operations-remove,edit-vaccines-add-submit,edit-vaccines-add-more-items,edit-wizard-next">
<noscript>
<div class="antibot-no-js antibot-message antibot-message-warning">You must have JavaScript enabled to use this form.</div>
</noscript>
<div class="webform-wizard-pages-links js-webform-wizard-pages-links form-group js-form-wrapper form-wrapper" data-wizard-progress-link="true" data-drupal-selector="edit-pages" id="edit-pages"></div>
<div class="webform-progress">
<ul class="webform-progress-tracker progress-tracker progress-tracker--center" data-webform-progress-steps="">
<li data-webform-page="step_one" title="Step One" class="progress-step is-active" aria-current="step">
<div class="progress-marker" data-webform-progress-step="" data-webform-progress-link="" data-text="1"></div>
<div class="progress-text">
<div class="progress-title" data-webform-progress-link="">
<span class="visually-hidden" data-webform-progress-state="">Current</span> Step One
</div>
</div>
</li>
<li data-webform-page="step_two" title="Step Two" class="progress-step">
<div class="progress-marker" data-webform-progress-step="" data-webform-progress-link="" data-text="2"></div>
<div class="progress-text">
<div class="progress-title" data-webform-progress-link="">
<span class="visually-hidden" data-webform-progress-state=""></span> Step Two
</div>
</div>
</li>
<li data-webform-page="step_three" title="Step Three" class="progress-step">
<div class="progress-marker" data-webform-progress-step="" data-webform-progress-link="" data-text="3"></div>
<div class="progress-text">
<div class="progress-title" data-webform-progress-link="">
<span class="visually-hidden" data-webform-progress-state=""></span> Step Three
</div>
</div>
</li>
<li data-webform-page="step_four" title="Step Four" class="progress-step">
<div class="progress-marker" data-webform-progress-step="" data-webform-progress-link="" data-text="4"></div>
<div class="progress-text">
<div class="progress-title" data-webform-progress-link="">
<span class="visually-hidden" data-webform-progress-state=""></span> Step Four
</div>
</div>
</li>
<li data-webform-page="webform_confirmation" title="Complete" class="progress-step">
<div class="progress-marker" data-webform-progress-step="" data-webform-progress-link="" data-text="5"></div>
<div class="progress-text">
<div class="progress-title" data-webform-progress-link="">
<span class="visually-hidden" data-webform-progress-state=""></span> Complete
</div>
</div>
</li>
</ul>
</div>
<div class="hidden form-item js-form-item form-type-checkbox js-form-type-checkbox form-item-pso js-form-item-pso checkbox">
<label for="edit-pso" class="control-label option"><input data-drupal-selector="edit-pso" class="form-checkbox" type="checkbox" id="edit-pso" name="pso" value="1" tabindex="0">
<span class="checkbox-mark"></span>PSO</label>
</div>
<div data-webform-key="step_one" data-drupal-selector="edit-step-one" class="js-form-wrapper form-wrapper form-group" id="edit-step-one--2">
<div id="edit-markup-03" class="form-item js-form-item form-type-webform-markup js-form-type-webform-markup form-item-markup-03 js-form-item-markup-03 form-no-label form-group">
<h3>Use the form below to report an error or hazard to the ISMP National Vaccine Errors Reporting Program</h3> 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).
</div>
<fieldset data-drupal-selector="edit-report-submission-type" class="radios--wrapper fieldgroup form-composite webform-composite-visible-title required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper"
id="edit-report-submission-type--wrapper">
<legend id="edit-report-submission-type--wrapper-legend">
<span class="fieldset-legend js-form-required form-required">Report submission type</span>
</legend>
<div class="fieldset-wrapper">
<div id="edit-report-submission-type" class="js-webform-radios webform-options-display-one-column">
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-report-submission-type js-form-item-report-submission-type radio">
<label for="edit-report-submission-type-error-occurred-and-reached-the-patient" class="control-label option"><input data-drupal-selector="edit-report-submission-type-error-occurred-and-reached-the-patient" class="form-radio" type="radio"
id="edit-report-submission-type-error-occurred-and-reached-the-patient" name="report_submission_type" value="Error occurred and reached the patient" required="required">Error occurred and reached the patient</label>
</div>
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-report-submission-type js-form-item-report-submission-type radio">
<label for="edit-report-submission-type-error-occurred-but-did-not-reach-the-patient" class="control-label option"><input data-drupal-selector="edit-report-submission-type-error-occurred-but-did-not-reach-the-patient" class="form-radio"
type="radio" id="edit-report-submission-type-error-occurred-but-did-not-reach-the-patient" name="report_submission_type" value="Error occurred but did NOT reach the patient" required="required">Error occurred but did NOT reach the
patient</label>
</div>
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-report-submission-type js-form-item-report-submission-type radio">
<label for="edit-report-submission-type-hazardous-condition-no-error-but-situation-warrants-concern" class="control-label option"><input
data-drupal-selector="edit-report-submission-type-hazardous-condition-no-error-but-situation-warrants-concern" class="form-radio" type="radio"
id="edit-report-submission-type-hazardous-condition-no-error-but-situation-warrants-concern" name="report_submission_type" value="Hazardous condition (no error, but situation warrants concern)" required="required">Hazardous condition
(no error, but situation warrants concern)</label>
</div>
</div>
</div>
</fieldset>
<div class="form-inline form-item js-form-item form-type-date js-form-type-date form-item-date-of-event-error js-form-item-date-of-event-error form-group">
<label for="edit-date-of-event-error" class="control-label js-form-required form-required">Please indicate the approximate date of the error or event or discovery of the medication safety concern</label>
<input min="7/24/2013" data-min-year="2013" max="7/24/2023" data-max-year="2023" type="text" data-drupal-date-format="n/j/Y" data-drupal-selector="edit-date-of-event-error" class="form-text required form-control hasDatepicker"
id="edit-date-of-event-error" name="date_of_event_error" value="" required="required" aria-required="true" autocomplete="chrome-off-32325359">
</div>
<section id="included-vaccines" data-drupal-selector="edit-vaccines-involved" class="required js-form-item form-item js-form-wrapper form-wrapper webform-section" required="required" aria-required="true">
<h2 class="webform-section-title js-form-required form-required">Vaccine(s) involved in this event</h2>
<div class="webform-section-wrapper">
<fieldset data-drupal-selector="edit-search-by" class="radios--wrapper fieldgroup form-composite webform-composite-visible-title js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper"
id="edit-search-by--wrapper">
<legend id="edit-search-by--wrapper-legend">
<span class="fieldset-legend">Search by</span>
</legend>
<div class="fieldset-wrapper">
<div id="edit-search-by" class="js-webform-radios webform-options-display-one-column">
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-search-by js-form-item-search-by radio">
<label for="edit-search-by-brand-name" class="control-label option"><input data-drupal-selector="edit-search-by-brand-name" class="form-radio" type="radio" id="edit-search-by-brand-name" name="search_by" value="Brand name"
checked="checked">Brand name</label>
</div>
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-search-by js-form-item-search-by radio">
<label for="edit-search-by-generic-name" class="control-label option"><input data-drupal-selector="edit-search-by-generic-name" class="form-radio" type="radio" id="edit-search-by-generic-name" name="search_by"
value="Generic name">Generic name</label>
</div>
<div class="form-item js-form-item form-type-radio js-form-type-radio form-item-search-by js-form-item-search-by radio">
<label for="edit-search-by-vaccine-abbreviation" class="control-label option"><input data-drupal-selector="edit-search-by-vaccine-abbreviation" class="form-radio" type="radio" id="edit-search-by-vaccine-abbreviation" name="search_by"
value="Vaccine abbreviation">Vaccine abbreviation</label>
</div>
</div>
</div>
</fieldset>
<div data-drupal-selector="edit-vaccine-add" class="form-group js-form-wrapper form-wrapper" id="edit-vaccine-add">
<div class="form-item js-form-item form-type-select js-form-type-select form-item-generic-name js-form-item-generic-name form-group" style="display: none;">
<label for="edit-generic-name" class="control-label">Generic name</label>
<div class="input-group">
<div class="select-wrapper"><select data-drupal-selector="edit-generic-name" class="webform-entity-select form-select form-control" id="edit-generic-name" name="generic_name"
data-drupal-states="{"visible":{".webform-submission-verp-form-add-form :input[name=\u0022search_by\u0022]":{"value":"Generic name"}}}" data-once="drupal-ajax">
<option value="" selected="selected">- None -</option>
<option value="18156">Adenovirus Type 4 and Type 7 Vaccine, Live, Oral</option>
<option value="18158">Anthrax Vaccine Adsorbed</option>
<option value="18186">BCG Live</option>
<option value="18198">Cholera Vaccine Live Oral</option>
<option value="23559">COVID-19 Vaccine (adenovirus)</option>
<option value="21764">COVID-19 Vaccine (mRNA)</option>
<option value="38465">COVID-19 Vaccine, Adjuvanted</option>
<option value="38464">COVID-19 Vaccine, Bivalent (mRNA)</option>
<option value="18379">Dengue Tetravalent Vaccine, Live</option>
<option value="18161">Diphtheria & Tetanus Toxoids & Acellular Pertussis Vaccine Adsorbed</option>
<option value="18175">Diphtheria & Tetanus Toxoids Adsorbed for Pediatric Use</option>
<option value="18170">Diphtheria, Tetanus, Acellular Pertussis, and Inactivated Polio Vaccine</option>
<option value="18177">Diphtheria, Tetanus, Acellular Pertussis, Hepatitis B, & Inactivated Poliovirus</option>
<option value="18179">Diphtheria, Tetanus, Acellular Pertussis, Inactivated Polio, and Haemophilus b</option>
<option value="18380">Diphtheria, Tetanus, Pertussis, Poliovirus, Haemophilus b, and Hepatitis B</option>
<option value="18381">Ebola Zaire Vaccine, Live</option>
<option value="18178">Haemophilus b Conjugate Vaccine (Meningococcal Protein Conjugate)</option>
<option value="18202">Haemophilus b Conjugate Vaccine (Tetanus Toxoid Conjugate)</option>
<option value="18187">Hepatitis A Inactivated and Hepatitis B [Recombinant] Vaccine</option>
<option value="18166">Hepatitis A Vaccine, Inactivated</option>
<option value="18162">Hepatitis B Vaccine [Recombinant]</option>
<option value="18199">Hepatitis B Vaccine [Recombinant], Adjuvanted</option>
<option value="18195">Human Papillomavirus 9-valent Vaccine, Recombinant</option>
<option value="18194">Influenza vaccine, adjuvanted</option>
<option value="18164">Influenza Vaccine, Live, Intranasal (Quadrivalent, Types A and Types B)</option>
<option value="18163">Influenza Vaccine, Live, Intranasal (Trivalent, Types A and B)</option>
<option value="18196">Influenza Virus Vaccine (Quadrivalent, Types A and Types B)</option>
<option value="18200">Influenza Virus Vaccine (Quadrivalent, Types A and Types B)</option>
<option value="18155">Influenza Virus Vaccine (Trivalent, Types A and B)</option>
<option value="18169">Japanese Encephalitis Virus Vaccine, Inactivated, Adsorbed</option>
<option value="18174">Measles, Mumps, and Rubella Virus Vaccine, Live</option>
<option value="18182">Measles, Mumps, Rubella and Varicella Virus Vaccine Live</option>
<option value="18173">Meningococcal (Groups A, C, Y, and W-135) Oligosaccharide Diphtheria CRM197</option>
<option value="38473">Meningococcal (Groups A, C, Y, W) Conjugate Vaccine</option>
<option value="18171">Meningococcal (Serogroups A, C, Y and W-135) Polysaccharide Diphtheria Toxoid Co</option>
<option value="18197">Meningococcal Group B Vaccine</option>
<option value="18181">Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]</option>
<option value="38482">Pneumococcal 15-valent Conjugate Vaccine</option>
<option value="38474">Pneumococcal 20-valent Conjugate Vaccine</option>
<option value="18180">Pneumococcal Vaccine, Polyvalent</option>
<option value="18168">Poliovirus Vaccine Inactivated [Monkey Kidney Cell]</option>
<option value="18167">Rabies Vaccine</option>
<option value="84228">Respiratory Syncytial Virus Vaccine</option>
<option value="84229">Respiratory Syncytial Virus Vaccine, Adjuvanted</option>
<option value="18183">Rotavirus Vaccine, Live, Oral</option>
<option value="18184">Rotavirus Vaccine, Live, Oral, Pentavalent</option>
<option value="18152">Smallpox (Vaccinia) Vaccine, Live</option>
<option value="38472">Smallpox and Monkeypox Vaccine, Live, Non-Replicating</option>
<option value="18185">Tetanus & Diphtheria Toxoids Adsorbed</option>
<option value="18176">Tetanus Toxoid Adsorbed</option>
<option value="18154">Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsor</option>
<option value="38496">Tick-borne Encephalitis Vaccine</option>
<option value="18190">Typhoid Vaccine Live Oral Ty21a</option>
<option value="18188">Typhoid Vi Polysaccharide Vaccine</option>
<option value="18189">Varicella Virus Vaccine Live</option>
<option value="18191">Yellow Fever Vaccine</option>
<option value="18153">Zoster Vaccine Recombinant, Adjuvanted</option>
</select></div><span class="input-group-addon"><span class="icon glyphicon glyphicon-refresh ajax-progress ajax-progress-throbber" aria-hidden="true"></span></span>
</div>
</div>
<div class="js-webform-states-hidden form-item js-form-item form-type-entity-autocomplete js-form-type-entity-autocomplete form-item-abbreviated-name js-form-item-abbreviated-name form-group form-autocomplete" style="display: none;">
<label for="edit-abbreviated-name" class="control-label">Vaccine abbreviation</label>
<div class="input-group"><input data-drupal-selector="edit-abbreviated-name" class="form-autocomplete form-text form-control ui-autocomplete-input"
data-autocomplete-path="/entity_reference_autocomplete/node/views/1z-jCFK1VPFj3qj5aUBaQ8HJ2ALSo3hkJlLJAEgD2dA" type="text" id="edit-abbreviated-name" name="abbreviated_name" value="" size="60"
data-drupal-states="{"visible":{".webform-submission-verp-form-add-form :input[name=\u0022search_by\u0022]":{"value":"Vaccine abbreviation"}}}" data-once="autocomplete drupal-ajax"
autocomplete="off"><span class="input-group-addon"><span class="icon glyphicon glyphicon-refresh ajax-progress ajax-progress-throbber" aria-hidden="true"></span></span></div>
</div>
<div id="branded-vaccines-dropdown">
<div class="form-item js-form-item form-type-select js-form-type-select form-item-brand-name js-form-item-brand-name form-group">
<label for="edit-brand-name" class="control-label">Brand name</label>
<div class="input-group">
<div class="select-wrapper"><select data-drupal-selector="edit-brand-name" class="webform-entity-select form-select form-control" id="edit-brand-name" name="brand_name" data-once="drupal-ajax">
<option value="" selected="selected">- None -</option>
<option value="84231">Abrysvo</option>
<option value="18241">ACAM2000</option>
<option value="18240">ActHIB</option>
<option value="18242">Adacel</option>
<option value="18243">Afluria</option>
<option value="18234">Afluria Quadrivalent</option>
<option value="18244">AgriFlu</option>
<option value="84230">Arexvy</option>
<option value="18294">BCG Vaccine</option>
<option value="18232">Bexsero</option>
<option value="18245">Biothrax</option>
<option value="18246">Boostrix</option>
<option value="27048">Comirnaty</option>
<option value="18248">Daptacel</option>
<option value="18382">Dengvaxia</option>
<option value="18250">Engerix-B</option>
<option value="18384">Ervebo</option>
<option value="18226">Fluad</option>
<option value="38497">Fluad Quadrivalent</option>
<option value="18224">Fluarix Quadrivalent</option>
<option value="18229">Flublok</option>
<option value="18237">Flublok Quadrivalent</option>
<option value="18230">Flucelvax</option>
<option value="18236">Flucelvax Quadrivalent</option>
<option value="18251">FluLaval</option>
<option value="18227">FluLaval Quadrivalent</option>
<option value="18252">FluMist</option>
<option value="18253">FluMist Quadrivalent</option>
<option value="18254">Fluvirin</option>
<option value="18256">Fluzone</option>
<option value="38492">Fluzone High-Dose Quadrivalent</option>
<option value="18228">Fluzone Quadrivalent</option>
<option value="18221">Gardasil 9</option>
<option value="18260">Havrix</option>
<option value="18235">Heplisav-B</option>
<option value="18259">Hiberix</option>
<option value="18261">Imovax Rabies</option>
<option value="18263">Infanrix</option>
<option value="18262">IPOL</option>
<option value="18264">Ixiaro</option>
<option value="23561">Janssen COVID-19 Vaccine</option>
<option value="38476">Jynneos</option>
<option value="18266">Kinrix</option>
<option value="18269">M-M-R II</option>
<option value="18265">Menactra</option>
<option value="38477">MenQuadfi</option>
<option value="18268">Menveo</option>
<option value="21767">Moderna COVID-19 Vaccine</option>
<option value="38468">Moderna COVID-19 Vaccine, Bivalent</option>
<option value="18292">No Brandname</option>
<option value="38469">Novavax COVID-19 Vaccine, Adjuvanted</option>
<option value="18270">Pediarix</option>
<option value="18271">PedvaxHIB</option>
<option value="18272">Pentacel</option>
<option value="21766">Pfizer-BioNTech COVID-19 Vaccine</option>
<option value="38467">Pfizer-BioNTech COVID-19 Vaccine, Bivalent</option>
<option value="18273">Pneumovax 23</option>
<option value="38485">PreHevbrio</option>
<option value="18274">Prevnar 13</option>
<option value="38478">Prevnar 20</option>
<option value="38486">Priorix</option>
<option value="18275">ProQuad</option>
<option value="18225">Quadracel</option>
<option value="18276">RabAvert</option>
<option value="18277">Recombivax HB</option>
<option value="18278">Rotarix</option>
<option value="18279">RotaTeq</option>
<option value="18239">Shingrix</option>
<option value="29620">Spikevax</option>
<option value="38498">TDVAX</option>
<option value="18280">Tenivac</option>
<option value="18281">TICE BCG</option>
<option value="38499">Ticovac</option>
<option value="18231">Trumenba</option>
<option value="18282">Twinrix</option>
<option value="18283">Typhim Vi</option>
<option value="18284">VAQTA</option>
<option value="18285">Varivax</option>
<option value="18233">Vaxchora</option>
<option value="18383">Vaxelis</option>
<option value="38484">Vaxneuvance</option>
<option value="18286">Vivotif</option>
<option value="18287">YF-Vax</option>
</select></div><span class="input-group-addon"><span class="icon glyphicon glyphicon-refresh ajax-progress ajax-progress-throbber" aria-hidden="true"></span></span>
</div>
</div>
</div>
<div id="brand-related-vaccines"></div>
<div class="webform-element--title-inline form-item js-form-item form-type-textfield js-form-type-textfield form-item-dosage js-form-item-dosage form-group">
<label for="edit-dosage" class="control-label">Dosage (optional)</label>
<input data-counter-type="character" data-counter-maximum="50" class="js-webform-counter webform-counter form-text form-control" data-drupal-selector="edit-dosage" type="text" id="edit-dosage" name="dosage" value="" size="60"
maxlength="50">
<div class="text-count-wrapper">
<div class="text-count-message" aria-live="polite" aria-atomic="true" style="display: inline;"><span class="text-count">50</span> character(s) remaining</div>
<div class="text-count-overflow-wrapper" style="display: none;"></div>
</div>
</div>
<div class="webform-element--title-inline form-item js-form-item form-type-textfield js-form-type-textfield form-item-lot js-form-item-lot form-group">
<label for="edit-lot" class="control-label">Lot # (optional)</label>
<input data-drupal-selector="edit-lot" class="form-text form-control" type="text" id="edit-lot" name="lot" value="" size="60" maxlength="255">
</div>
<div class="webform-element--title-inline form-inline form-item js-form-item form-type-date js-form-type-date form-item-expiration-date js-form-item-expiration-date form-group">
<label for="edit-expiration-date" class="control-label">Expiration date (optional)</label>
<input type="text" data-drupal-date-format="n/j/Y" data-drupal-selector="edit-expiration-date" class="form-text form-control hasDatepicker" id="edit-expiration-date" name="expiration_date" value="" autocomplete="chrome-off-82921124">
</div>
<div class="webform-element--title-inline form-item js-form-item form-type-textfield js-form-type-textfield form-item-ndc js-form-item-ndc form-group">
<label for="edit-ndc" class="control-label">NDC (optional)</label>
<input data-drupal-selector="edit-ndc" class="form-text form-control" type="text" id="edit-ndc" name="ndc" value="" size="60" maxlength="255">
</div>
</div>
<button data-drupal-selector="edit-add-vaccine" class="button js-form-submit form-submit btn-success btn" type="submit" id="edit-add-vaccine" name="op" value="Add vaccine to report" data-once="drupal-ajax">Add vaccine to report</button>
<div id="vaccines_table">
<div id="edit-vaccines" class="form-item js-form-item form-type-webform-custom-composite js-form-type-webform-custom-composite form-item-vaccines js-form-item-vaccines form-group">
<label class="control-label">Vaccines included in this report</label>
<div class="webform-multiple-table webform-multiple-table-responsive">
<div class="table-responsive">
<div class="tableresponsive-toggle-columns"><button type="button" class="link tableresponsive-toggle" title="Show table cells that were hidden to make the table fit within a small screen." style="display: none;">Hide lower priority
columns</button></div>
<table data-drupal-selector="edit-vaccines-items" class="responsive-enabled table table-hover table-striped" id="edit-vaccines-items" data-striping="1" data-once="tableresponsive">
<thead>
<tr>
<th class="vaccines-table--brand_name webform-multiple-table--brand_name">Brand name</th>
<th class="vaccines-table--generic_name webform-multiple-table--generic_name">Generic name</th>
<th class="vaccines-table--manufacturer webform-multiple-table--manufacturer">Manufacturer</th>
<th class="vaccines-table--operations webform-multiple-table--operations"><span class="visually-hidden">Operations</span></th>
</tr>
</thead>
<tbody>
<tr data-drupal-selector="edit-vaccines-items-0" class="odd">
<td class="webform-readonly">
<div class="webform-readonly form-item js-form-item form-type-textfield js-form-type-textfield form-item-vaccines-items-0-brand-name js-form-item-vaccines-items-0-brand-name form-no-label form-group">
<label for="edit-vaccines-items-0-brand-name" class="control-label sr-only">Brand name</label>
<input readonly="readonly" data-drupal-selector="edit-vaccines-items-0-brand-name" class="form-text form-control" type="text" id="edit-vaccines-items-0-brand-name" name="vaccines[items][0][brand_name]" value="" size="60"
maxlength="255">
</div>
</td>
<td class="webform-readonly">
<div class="webform-readonly form-item js-form-item form-type-textfield js-form-type-textfield form-item-vaccines-items-0-generic-name js-form-item-vaccines-items-0-generic-name form-no-label form-group">
<label for="edit-vaccines-items-0-generic-name" class="control-label sr-only">Generic name</label>
<input readonly="readonly" data-drupal-selector="edit-vaccines-items-0-generic-name" class="form-text form-control" type="text" id="edit-vaccines-items-0-generic-name" name="vaccines[items][0][generic_name]" value=""
size="60" maxlength="255">
</div>
</td>
<td class="webform-readonly">
<div class="webform-readonly form-item js-form-item form-type-textfield js-form-type-textfield form-item-vaccines-items-0-manufacturer js-form-item-vaccines-items-0-manufacturer form-no-label form-group">
<label for="edit-vaccines-items-0-manufacturer" class="control-label sr-only">Manufacturer</label>
<input readonly="readonly" data-drupal-selector="edit-vaccines-items-0-manufacturer" class="form-text form-control" type="text" id="edit-vaccines-items-0-manufacturer" name="vaccines[items][0][manufacturer]" value=""
size="60" maxlength="255">
</div>
</td>
<td class="webform-multiple-table--operations webform-multiple-table--operations-two"><button data-drupal-selector="edit-vaccines-items-0-operations-add" formnovalidate="formnovalidate"
class="image-button js-form-submit form-submit btn-success hidden btn" type="image" id="edit-vaccines-items-0-operations-add" name="vaccines_table_add_0" src="/modules/contrib/webform/images/icons/plus.svg"
alt="Add new item after item 1" title="Add new item after item 1" data-once="drupal-ajax">Add new item after item 1</button><button data-drupal-selector="edit-vaccines-items-0-operations-remove"
formnovalidate="formnovalidate" class="image-button js-form-submit form-submit btn-danger btn icon-before" type="image" id="edit-vaccines-items-0-operations-remove" name="vaccines_table_remove_0"
src="/modules/contrib/webform/images/icons/minus.svg" alt="Remove item 1" title="Remove item 1" data-once="drupal-ajax"><span class="icon glyphicon glyphicon-trash" aria-hidden="true"></span> Remove item 1</button></td>
<td style="display: none"><input data-drupal-selector="edit-vaccines-items-0-hidden-type-of-vaccine" type="hidden" name="vaccines[items][0][_hidden_][type_of_vaccine]" value=""><input
data-drupal-selector="edit-vaccines-items-0-hidden-dosage" type="hidden" name="vaccines[items][0][_hidden_][dosage]" value=""><input data-drupal-selector="edit-vaccines-items-0-hidden-lot" type="hidden"
name="vaccines[items][0][_hidden_][lot]" value="">
<div class="form-item js-form-item form-type-hidden js-form-type-hidden form-item-vaccines-items-0--hidden--expiration-date js-form-item-vaccines-items-0--hidden--expiration-date form-no-label">
<label for="edit-vaccines-items-0-hidden-expiration-date" class="control-label sr-only">Expiration date</label>
<input type="hidden" data-drupal-selector="edit-vaccines-items-0-hidden-expiration-date" name="vaccines[items][0][_hidden_][expiration_date]" value="">
</div>
<input data-drupal-selector="edit-vaccines-items-0-hidden-ndc" type="hidden" name="vaccines[items][0][_hidden_][ndc]" value=""><input data-drupal-selector="edit-vaccines-items-0-hidden-brand-nid" type="hidden"
name="vaccines[items][0][_hidden_][brand_nid]" value=""><input data-drupal-selector="edit-vaccines-items-0-hidden-generic-nid" type="hidden" name="vaccines[items][0][_hidden_][generic_nid]" value=""><input
data-drupal-selector="edit-vaccines-items-0-hidden-manufacturer-nid" type="hidden" name="vaccines[items][0][_hidden_][manufacturer_nid]" value="">
</td>
</tr>
</tbody>
</table>
</div>
</div>
<div class="webform-multiple-add js-webform-multiple-add container-inline"><button data-drupal-selector="edit-vaccines-add-submit" formnovalidate="formnovalidate" class="button js-form-submit form-submit btn-success hidden btn"
type="submit" id="edit-vaccines-add-submit" name="vaccines_table_add" value="Add" data-once="drupal-ajax">Add</button>
<div class="form-inline hidden form-item js-form-item form-type-number js-form-type-number form-item-vaccines-add-more-items js-form-item-vaccines-add-more-items form-no-label form-group">
<label for="edit-vaccines-add-more-items" class="control-label sr-only">Add more items</label>
<input data-drupal-selector="edit-vaccines-add-more-items" class="form-number form-control" type="number" id="edit-vaccines-add-more-items" name="vaccines[add][more_items]" value="1" step="1" min="1" max="100"> more items
</div>
</div>
<div class="description help-block">
<div id="edit-vaccines--description" class="webform-element-description form-group">'Remove' will remove all of the added vaccines.</div>
</div>
</div>
</div>
</div>
</section>
</div>
<input autocomplete="off" data-drupal-selector="form-wnsupqrlb4v4ulzpziwcahvcdjacdiqz3a216nljw4g" type="hidden" name="form_build_id" value="form-wNSUPqrlb4V4ULZpZIwcahvcdjaCdiQZ3a216NlJW4g"><input
data-drupal-selector="edit-webform-submission-verp-form-add-form" type="hidden" name="form_id" value="webform_submission_verp_form_add_form"><input data-drupal-selector="edit-antibot-key" type="hidden" name="antibot_key" value="">
<div data-drupal-selector="edit-actions" class="form-actions form-group js-form-wrapper form-wrapper" id="edit-actions--2"><button class="webform-button--next button js-form-submit form-submit btn-default btn"
data-drupal-selector="edit-wizard-next" type="submit" id="edit-wizard-next" name="op" value="Next Page >">Next Page ></button>
</div>
</form>Text Content
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HEALTHCARE PRACTITIONER’S VACCINE ERROR REPORTING FORM
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PSO
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
- None -Adenovirus Type 4 and Type 7 Vaccine, Live, OralAnthrax Vaccine
AdsorbedBCG LiveCholera Vaccine Live OralCOVID-19 Vaccine (adenovirus)COVID-19
Vaccine (mRNA)COVID-19 Vaccine, AdjuvantedCOVID-19 Vaccine, Bivalent
(mRNA)Dengue Tetravalent Vaccine, LiveDiphtheria & Tetanus Toxoids & Acellular
Pertussis Vaccine AdsorbedDiphtheria & Tetanus Toxoids Adsorbed for Pediatric
UseDiphtheria, Tetanus, Acellular Pertussis, and Inactivated Polio
VaccineDiphtheria, Tetanus, Acellular Pertussis, Hepatitis B, & Inactivated
PoliovirusDiphtheria, Tetanus, Acellular Pertussis, Inactivated Polio, and
Haemophilus bDiphtheria, Tetanus, Pertussis, Poliovirus, Haemophilus b, and
Hepatitis BEbola Zaire Vaccine, LiveHaemophilus b Conjugate Vaccine
(Meningococcal Protein Conjugate)Haemophilus b Conjugate Vaccine (Tetanus Toxoid
Conjugate)Hepatitis A Inactivated and Hepatitis B [Recombinant] VaccineHepatitis
A Vaccine, InactivatedHepatitis B Vaccine [Recombinant]Hepatitis B Vaccine
[Recombinant], AdjuvantedHuman Papillomavirus 9-valent Vaccine,
RecombinantInfluenza vaccine, adjuvantedInfluenza Vaccine, Live, Intranasal
(Quadrivalent, Types A and Types B)Influenza Vaccine, Live, Intranasal
(Trivalent, Types A and B)Influenza Virus Vaccine (Quadrivalent, Types A and
Types B)Influenza Virus Vaccine (Quadrivalent, Types A and Types B)Influenza
Virus Vaccine (Trivalent, Types A and B)Japanese Encephalitis Virus Vaccine,
Inactivated, AdsorbedMeasles, Mumps, and Rubella Virus Vaccine, LiveMeasles,
Mumps, Rubella and Varicella Virus Vaccine LiveMeningococcal (Groups A, C, Y,
and W-135) Oligosaccharide Diphtheria CRM197Meningococcal (Groups A, C, Y, W)
Conjugate VaccineMeningococcal (Serogroups A, C, Y and W-135) Polysaccharide
Diphtheria Toxoid CoMeningococcal Group B VaccinePneumococcal 13-valent
Conjugate Vaccine [Diphtheria CRM197 Protein]Pneumococcal 15-valent Conjugate
VaccinePneumococcal 20-valent Conjugate VaccinePneumococcal Vaccine,
PolyvalentPoliovirus Vaccine Inactivated [Monkey Kidney Cell]Rabies
VaccineRespiratory Syncytial Virus VaccineRespiratory Syncytial Virus Vaccine,
AdjuvantedRotavirus Vaccine, Live, OralRotavirus Vaccine, Live, Oral,
PentavalentSmallpox (Vaccinia) Vaccine, LiveSmallpox and Monkeypox Vaccine,
Live, Non-ReplicatingTetanus & Diphtheria Toxoids AdsorbedTetanus Toxoid
AdsorbedTetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis
Vaccine, AdsorTick-borne Encephalitis VaccineTyphoid Vaccine Live Oral
Ty21aTyphoid Vi Polysaccharide VaccineVaricella Virus Vaccine LiveYellow Fever
VaccineZoster Vaccine Recombinant, Adjuvanted
Vaccine abbreviation
Brand name
- None -AbrysvoACAM2000ActHIBAdacelAfluriaAfluria QuadrivalentAgriFluArexvyBCG
VaccineBexseroBiothraxBoostrixComirnatyDaptacelDengvaxiaEngerix-BErveboFluadFluad
QuadrivalentFluarix QuadrivalentFlublokFlublok QuadrivalentFlucelvaxFlucelvax
QuadrivalentFluLavalFluLaval QuadrivalentFluMistFluMist
QuadrivalentFluvirinFluzoneFluzone High-Dose QuadrivalentFluzone
QuadrivalentGardasil 9HavrixHeplisav-BHiberixImovax
RabiesInfanrixIPOLIxiaroJanssen COVID-19 VaccineJynneosKinrixM-M-R
IIMenactraMenQuadfiMenveoModerna COVID-19 VaccineModerna COVID-19 Vaccine,
BivalentNo BrandnameNovavax COVID-19 Vaccine,
AdjuvantedPediarixPedvaxHIBPentacelPfizer-BioNTech COVID-19
VaccinePfizer-BioNTech COVID-19 Vaccine, BivalentPneumovax 23PreHevbrioPrevnar
13Prevnar 20PriorixProQuadQuadracelRabAvertRecombivax
HBRotarixRotaTeqShingrixSpikevaxTDVAXTenivacTICE BCGTicovacTrumenbaTwinrixTyphim
ViVAQTAVarivaxVaxchoraVaxelisVaxneuvanceVivotifYF-Vax
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Expiration date (optional)
NDC (optional)
Add vaccine to report
Vaccines included in this report
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Brand name Generic name Manufacturer Operations
Brand name
Generic name
Manufacturer
Add new item after item 1 Remove item 1
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Add more items more items
'Remove' will remove all of the added vaccines.
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