You can download and print the various forms and other documents applicable to the Program.
All Program forms must be completed and submitted in English, French, or Portuguese; any form completed or submitted in any other language will be rejected. However, documents and other information that should be provided alongside the Application Form (Schedule 2), the Supporting Evidence Form (Schedule 3) or the Appeal of Denied Receivable Claim form (Schedule 5), as described in such forms, may be submitted in other languages.
All Program forms must be duly completed, signed and dated when submitted, in order to be considered by the Administrator.
In addition to the Schedules above, there are other helpful documents that an Applicant should refer to, including the Program’s Protocol and the definitions used in the Program Protocol and on this site.
The AVAT No Fault Compensation Scheme, as detailed in the Protocol and its Schedules.
A written claim for compensation completed by an Applicant on the application form approved by and provided by the Administrator, as set forth in Schedule 2 to the Program's Protocol, which must be accompanied by all Supporting Evidence, using the prescribed form in Schedule 3 to the Program’s Protocol.
The supporting evidence, using the form in Schedule 3 to the Program's Protocol, required to evaluate an Application and that shall include:
- detailed medical documentation from a Registered Health Professional describing the Injury and medical treatment required as a result of the Injury, together with details of any Hospitalization or prolonged Hospitalization, including but not limited to admission and discharge records;
- a description of the nature, extent, functional impact and prognosis of the Injury, as assessed by the Registered Health Professional.
- a statement from the Registered Health Professional that the Injury was, in the Registered Health Professional’s opinion, the result of the Vaccine or its administration;
- certification from a Registered Health Professional of when, where and which Vaccine was administered;
- in the case of death, a death certificate and any other documentation available from a Registered Health Professional of the cause and manner of death; and
- any further evidence that the Administrator may deem necessary to adjudicate the Application, and/or Receivable Claim, as applicable, guided, as appropriate, by the Scientific Advisory Committee, the Review Panel, and/or the Appeals Panel.
Any duly completed Application for compensation (i) that is accompanied by all Supporting Evidence, (ii) that is filed/submitted by an Applicant prior to the end of the Reporting Period with the Administrator, and (iii) that is found by the Administrator, and/or by the Administrator’s Vice President of Risk Consulting to be receivable as provided in Section 4 or Section 7 of the Program's Protocol.
ESIS, Inc., the claims Administrator appointed to manage and administer the Program, including, but not limited to, the receipt and registration of Applications, distributing acknowledgements of receipt of Applications, setting financial reserves for Receivable Claims, review of Applications, Supporting Evidence, and other documents to assess receivability, assessing Receivable Claims, and approve or deny, as the case may be, Payment for compensation, in accordance with the terms of the Program's Protocol.
A COVID-19 vaccine received in any Participating Member State through the AVAT Framework that:
- either (A) has licensure or authorization from a stringent (“functional”) regulatory authority or (B) has received WHO prequalification, following licensure or authorization from a stringent (“functional”) regulatory authority, or (C) has been issued authorization for emergency use based on licensure or authorization by a stringent (“functional”) regulatory authority; and
- is included in Schedule 1 to the Program's Protocol, as updated from time to time; and
- has received all required approvals and authorizations for importation, distribution, and use in the relevant Participating Member State; and
- has not reached its Scope of Coverage Endpoint.
A pan-African and pan-Caribbean no fault compensation program established by the AVAT NFCS Trust and administered by the Administrator with the aim of providing compensation to Patients who suffer an Injury (the most likely cause of such Injury (based on the balance of probabilities) being the result of a Vaccine or its administration, without the need for the Patient to demonstrate a defect in the relevant Vaccine or any fault by any person.
Either (as the context requires):
- The Patient who directly submits an Application for compensation under the Program for himself; or
- In the event the Patient has died, is a child, or is disabled or otherwise lacks the legal capacity to submit an Application for himself, then the Applicant must be a person who is a duly authorized legal heir (in the case of death), parent, legal guardian, or other legal representative of the Patient.
An appeal filed by an Applicant, following the denial of receivability of his Application by the Administrator, in accordance with the procedure described in Section 7 of the Program's Protocol and using the form in Schedule 4 to the Program's Protocol.
An appeal filed by a Claimant, following the denial of his Receivable Claim by the Review Panel, in accordance with the procedure described in Section 8 of the Program's Protocol and using the form in Schedule 5 of the Program's Protocol.
On a per Vaccine basis, the period during which an Applicant may file an Application for compensation under the Program in respect of such Vaccine. The maximum Reporting Period for each Vaccine extends from:
- the date on which such Vaccine was first put into circulation by the manufacturer within the AVAT Framework, following regulatory approval or an emergency use authorization of such Vaccine by any regulator (as indicated in Schedule 1 to the Program's Protocol); and
- terminates on the date which is 36 calendar months immediately after the Scope of Coverage Endpoint for such Vaccine (as indicated in Schedule 1 to the Program's Protocol), provided always that the Vaccine was administered before this Vaccine’s Scope of Coverage Endpoint (as defined in Section 2 of the Program's Protocol and indicated in Schedule 1 to the Program's Protocol). See the illustrative diagram of the Reporting Period attached as Schedule 7 to the Program's Protocol. For each Patient, the Reporting Period depends on the date the Vaccine was administered to the Patient. To calculate the Reporting Period that applies to the Patient, the Patient (or a person who is a duly authorized to represent the Patient as provided in part (ii) of the definition of Applicant in the Program's Protocol) needs to:
- determine (through Schedule 1 to the Program's Protocol) what is the date of the Scope of Coverage End Point that applies to the Vaccine that was administered to Patient; and
- calculate the number of months and days from the vaccination date (i.e. date that the Vaccine was administered to the Patient) until the date of the Vaccine’s Scope of Coverage End Point, and add another 36 months. This establishes the Reporting Period that applies to the Patient.