COVID After Vaccine: Anecdotal Reporting


One of the issues that emergency physicians are interested in is how effective the vaccines are, especially with several variants that are emerging. 

If you have evaluated patients who have been vaccinated and now have presumed or confirmed COVID-19, please complete this form (it should take less than 2 minutes). 

The data from your feedback will be used in aggregate to help inform additional resources and studies. 

In addition to filling out this short form, please culture the patient (RT-PCR) and have the lab send the specimen to your local health department marked "suspected vaccine breakthrough." 

This should help track geographic distribution of vaccine breakthroughs to discover trends in certain areas. It can take 3 to 6 weeks for samples to have genomic analysis, so the information you provide on this form can serve as an early alert system.
 
 
 
 
 
 
 
 
Patient's age
 
 
 
 
 
Patient's sex
 
Female
Male
Other
Transgender
 
 
 
 
State where patient was seen?
Or country if outside the United States
 
 
 
 
 
Which vaccine?
 
Pfizer (BNT162b2)
Moderna (MRNA-1273)
Janssen / Johnson & Johnson
AstraZeneca
Novavax
 
 
 
 
Number of shots
 
First / Single Dose
Second
 
 
 
 
Approximate date of patient's last shot - DD/MM/YEAR
 
 
 
 
 
Date of COVID-19 symptom onset - DD/MM/YEAR
 
 
 
 
 
How was COVID diagnosed?
 
Confirmed by testing
Suspected from symptoms
 
 
 
 
What was the patient's disposition?
 
Discharged
Admitted
ICU
Still in ED
Deceased
Other - please describe
 
 
 
 
Any other information that may be important to note: