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Washington State Department of Health Seasonal Influenza Vaccine Incident Return and Report Form 20152016 Influenza Season Vaccine(s) Only Date: Provider PIN: Returned By: Provider Name: Telephone:
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What is Seasonal Influenza Vaccine Incident Return and Report Form?

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Seasonal influenza vaccine incident refers to any adverse event or incident related to the administration of the seasonal flu vaccine.
Healthcare providers, vaccine manufacturers, and other entities involved in the distribution and administration of the seasonal influenza vaccine are required to file reports on vaccine incidents.
To fill out a seasonal influenza vaccine incident report, one must provide detailed information about the patient, the vaccine manufacturer, healthcare provider, the type of incident, and any relevant medical records.
The purpose of reporting seasonal influenza vaccine incidents is to monitor the safety and efficacy of the vaccine, detect any patterns of adverse events, and prevent potential harm to patients.
Information that must be reported on a seasonal influenza vaccine incident includes patient demographics, vaccine lot number, date of administration, type of adverse event, and any treatment provided.
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