Canadian Adverse Event Reporting System
Each Submission will generate a Unique-ID Number. All Fields marked with (*) are considered mandatory to complete the submission.
Mandatory Field
This form will only accept the first three digits of your postal code. This information is used for Sorting purposes only.
This is a mandatory field as your submission will require double-opt in. After Submitting you will receive an email link to verify that you wish to submit this information. You will also have the option to Opt-Out at any time.
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This is not a mandatory field, however in the event that you wish to have a follow up with a member of our triage team via phone the option is there.
Please Provide a Brief Answer
Please provide the Lot # which is visible on your proof of vaccination record. As our reporting system matures, we will be able to identify if there are any connections between Vaccine Lot # and adverse events. This field is not mandatory*
Please provide a brief medical history which will enable our team to better understand your reaction. ie: Diabetes, Heart Disease, COPD, Neurological etc.
You may choose more than one
if so please indicate the method you would prefer
Please indicate how your reaction has impacted you on a personal level. This specific entry may be made public in the form of an anonymous testimonial if you indicate consent below.
One of our goals is to make sure peoples voices are heard and to bring awareness to the real adverse events that are happening to people in Canada.
I Consent for CAERS to use the information provided to examine the nature of my adverse reaction and to create a reporting system identifying trends or signals from the conglomerate of data collected.