6. Every health professional referred to in section 69 of the Act must provide to the public health director of the professional’s territory, in addition to the information provided for in that section, the following information, insofar as it is available:(1) the date of birth, sex and estimated age at vaccination time of the person concerned;
(2) the vaccination date, the brand name of the vaccine administered or the name of the immunizing agent and the lot number of the vaccine administered;
(3) the dose number, the lot number of the adjuvant, the injection site and administration route of the vaccine administered, the quantity administered and the unit of measurement of the vaccine administered;
(4) the socio-sanitary region where the person concerned resides or, if vaccination did not take place in Québec, the Canadian province or country where vaccination took place;
(5) the time elapsed between vaccination and the beginning of the unusual clinical manifestation;
(6) identification of the unusual clinical manifestation;
(7) a description of the unusual clinical manifestation;
(8) the duration of the unusual clinical manifestation;
(9) immunization errors observed in connection with the unusual clinical manifestation, if applicable;
(10) the evolution of the incident at the time of reporting and at the time of the follow-up, if applicable;
(11) an indication that the person concerned is pregnant and the expected date of delivery, if applicable;
(12) the type of any medical consultation relating to the unusual clinical manifestation, if applicable;
(13) the date of any admission to a hospital centre in connection with the unusual clinical manifestation and the duration of hospitalization, if applicable;
(14) an indication that a current hospitalization is extended following the unusual clinical manifestation and the duration of that extension, if applicable;
(15) the severity of the case;
(16) a description of the treatment received, if applicable;
(17) the medication history of the person concerned at the time of vaccine administration, in connection with the unusual clinical manifestation;
(18) a description of the health problems, illnesses, allergies and acute lesions of the person concerned that are known at the time of vaccine administration, in connection with the unusual clinical manifestation;
(19) a description of the unusual clinical manifestations associated with vaccination that appeared previously in the person concerned, if applicable;
(20) the date of death of the person concerned, if applicable;
(21) the position of the person reporting the unusual clinical manifestation and the socio-sanitary region of the report;
(22) the date of the report.