caers

Canadian Adverse Event Reporting System
Each Submission will generate a Unique-ID Number. All Fields marked with (*) are considered mandatory to complete the submission.

Province *

Mandatory Field
Postal Code (First 3 Digits) *
This form will only accept the first three digits of your postal code. This information is used for Sorting purposes only.
Email *
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.
Phone
###–###–####

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.
Age *
Sex *

Female

Male
Date of First dose *

dd-MMM-yyyy
Vaccine Type – 1st Dose *
Date of second dose

dd-MMM-yyyy
Vaccine Type – Second Dose
Date of booster dose

dd-MMM-yyyy
Vaccine Type – Booster Shot
Date of 2nd Booster dose

dd-MMM-yyyy
Vaccine Type – Second Booster
Date of Reaction Onset *

dd-MMM-yyyy
How long after Injection did your reaction begin? *
Please Provide a Brief Answer
Vaccine Lot #
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*
Which Dose did you experience your reaction? *

1st Dose

2nd Dose

Booster
Have you ever tested positive for COVID-19 *

Yes – PCR

Yes – Rapid Test

No
I am submitting this adverse event report for *

Myself

Dependent under the age of (18)

A family member who is deceased or is unable to submit for themselves
Description of Adverse Event (Symptoms, Severity) *
Please Indicate which of the following best represents your situation *

My adverse reaction has been fully resolved with no further symptoms (No Medical Intervention)

My adverse reaction is a chronic ongoing issue (Not being treated Medically)

My adverse reaction is a chronic ongoing issue (Which I am presently being treated for)

My adverse reaction has been resolved to the best of my knowledge (After receiving medical attention)
Broad Medical History *
Please provide a brief medical history which will enable our team to better understand your reaction. ie: Diabetes, Heart Disease, COPD, Neurological etc.
My reaction was reported to one or more of the Following *

Healthcare Practicioner

Emergency Department Physician

Specialist

My reaction was reported and dismissed by all or one of the above

My reaction was reported but subsequently denied by Public Health or Health Canada

You may choose more than one
Do you wish to be contacted by one of our Health Care Facilitators regarding your adverse event? *

Yes – Via Phone

Yes – Via Email

No – I do not wish to be contacted

if so please indicate the method you would prefer
Follow up language preference *

English

French
Occupation
Flight Crew (Pilot)
What was your reason for receiving the Vaccine? *

Personal Choice

Employment Requirement

Travel Requirement

Trusted Public health or Healthcare Practicioner

Social responsibility or Inclusion (Ex: Protecting at risk persons or Peer/Social Pressure)
Would you be interested in participating in Podcasts with CAERS or any of it’s Collaborators? *

Yes

No
Testimony
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.
Do you give consent for your testimony to be used on our Website or Social Media (Identity remains confidential) *

Yes I Consent

No I do not Consent

I would like to Submit a Testimony or Story of my own at a later time

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.
Consent to use the information collected *
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.
Verification Code *
Enter text below – Entry is CASE SENSITIVE

Canadian Adverse Event Reporting System