Hepatitis B Vaccine Information

Name

Email Address

Phone

Vaccine Injured By: Vaccine Injured By:Haemophilus influenzae type b (Hib) vaccinesHepatitis A vaccinesHepatitis B vaccinesHuman papillomavirus (HPV) vaccinesMeasles — Vaccines containing measles virus (e.g., MMR, MM, MMRV)Measles, Mumps, and Rubella — Vaccines containing measles, mumps, and rubella virus or any of its components (e.g., MMR, MM, MMRV)Meningococcal vaccinesPneumococcal conjugate vaccinesPertussis — Vaccines containing whole cell pertussis bacteria, extracted or partial cell pertussis bacteria, or specific pertussis antigen(s) (e.g., DTP, DTaP, P, DTPHib)Polio — Vaccines containing polio live virus (OPV)Polio — Vaccines containing polio inactivated virus (e.g., IPV)Rotavirus vaccineRubella — Vaccines containing rubella virus (e.g., MMR, MMRV)Seasonal influenza vaccinesTetanus — Vaccines containing tetanus toxoid (e.g., DTaP, DTP, DT, Td, or TT)Varicella vaccinesOther — Any new vaccine recommended by the Centers for Disease Control and Prevention for routine administration to children, after publication by the Secretary of a notice of coverage

Illness, disability, injury or condition caused by Haemophilus influenzae type b (Hib) vaccines Illness, disability, injury or condition caused by Haemophilus influenzae type b (Hib) vaccines Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Hepatitis A vaccines Illness, disability, injury or condition caused by Hepatitis A vaccines Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Hepatitis B vaccines Illness, disability, injury or condition caused by Hepatitis B vaccines Anaphylaxis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Human papillomavirus (HPV) vaccines Illness, disability, injury or condition caused by Human papillomavirus (HPV) vaccines Anaphylaxis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Measles Vaccine (e.g., MMR, MM, MMRV) Illness, disability, injury or condition caused by Measles Vaccine (e.g., MMR, MM, MMRV) Thrombocytopenic purpura Vaccine-Strain Measles Viral Infection in an immunodeficient recipient

Illness, disability, injury or condition caused by . Vaccines containing measles, mumps, and rubella virus or any of its components (e.g., MMR, MM, MMRV) Illness, disability, injury or condition caused by . Vaccines containing measles, mumps, and rubella virus or any of its components (e.g., MMR, MM, MMRV) Anaphylaxis Encephalopathy or encephalitis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Meningococcal vaccines Illness, disability, injury or condition caused by Meningococcal vaccines Anaphylaxis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Pneumococcal conjugate vaccines Illness, disability, injury or condition caused by Pneumococcal conjugate vaccines Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Vaccines containing whole cell pertussis bacteria, extracted or partial cell pertussis bacteria, or specific pertussis antigen(s) (e.g., DTP, DTaP, P, DTPHib) Illness, disability, injury or condition caused by Vaccines containing whole cell pertussis bacteria, extracted or partial cell pertussis bacteria, or specific pertussis antigen(s) (e.g., DTP, DTaP, P, DTPHib) Anaphylaxis Encephalopathy or encephalitis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Vaccines containing polio live virus (OPV) Illness, disability, injury or condition caused by Vaccines containing polio live virus (OPV) Paralytic Polio in a non-immunodeficient recipient Paralytic Polio in an immunodeficient recipient Paralytic Polio in a vaccine associated community case Vaccine-Strain Polio Viral Infection in a non-immunodeficient recipient Vaccine-Strain Polio Viral Infection in an immunodeficient recipient Vaccine-Strain Polio Viral Infection in a vaccine associated community case

Illness, disability, injury or condition caused by Vaccines containing polio inactivated virus (e.g., IPV) Illness, disability, injury or condition caused by Vaccines containing polio inactivated virus (e.g., IPV) Anaphylaxis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Rotavirus vaccine Illness, disability, injury or condition caused by Rotavirus vaccine Intussusception

Illness, disability, injury or condition caused by vaccines containing Rubella virus (e.g., MMR, MMRV) Illness, disability, injury or condition caused by vaccines containing Rubella virus (e.g., MMR, MMRV) Chronic arthritis

Illness, disability, injury or condition caused by Seasonal influenza vaccines Illness, disability, injury or condition caused by Seasonal influenza vaccines Anaphylaxis Shoulder Injury Related to Vaccine Administration Vasovagal syncope Guillain-Barré Syndrome

Illness, disability, injury or condition caused by Vaccines containing tetanus toxoid (e.g., DTaP, DTP, DT, Td, or TT) Illness, disability, injury or condition caused by Vaccines containing tetanus toxoid (e.g., DTaP, DTP, DT, Td, or TT) Anaphylaxis Brachial Neuritis Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Varicella vaccines Illness, disability, injury or condition caused by Varicella vaccines Anaphylaxis Disseminated varicella vaccine-strain viral disease Varicella vaccine-strain viral reactivation Shoulder Injury Related to Vaccine Administration Vasovagal syncope

Illness, disability, injury or condition caused by Any new vaccine recommended by the Centers for Disease Control and Prevention for routine administration to children, after publication by the Secretary of a notice of coverage Illness, disability, injury or condition caused by Any new vaccine recommended by the Centers for Disease Control and Prevention for routine administration to children, after publication by the Secretary of a notice of coverage Shoulder Injury Related to Vaccine Administration Vasovagal syncope