Report an Adverse Event with a Writable PDF Form

Warning: This application works best on a desktop or laptop computer. Please continue on a secure computer.

Step 1 - Instructions for Downloading the Writable PDF Form

  • Download the form and save it to your computer
    Right click on the "Download the Writable PDF Form" button below, then select "Save Link As" or "Save Target As" to save the form to your computer. Form last updated on July 2024.
  • Complete the form electronically on your own time
    Use Acrobat 5.0 (or later) to open the file and fill the VAERS Writable PDF Form.
  • Save your completed form
    Use a computer where you can securely save a document that contains protected health information, personal identifiers or other sensitive personal or patient information.
  • Submit to VAERS using the "Upload the Writable PDF Form" button in Step 2

Important: Use a desktop or laptop computer on which you can securely save a document that contains protected health information, personal identifiers or other sensitive personal or patient information.

Download the Writable PDF Form

VAERS is co-sponsored by the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), agencies of the U.S. Department of Health and Human Services (HHS).