Adverse Reaction Reporting Form

To report an adverse drug reaction please fill out the form below, scroll to the bottom of the page and click “Submit”

A. Patient Information

Patient Identifier

Age at time of reaction

Sex

Male

Female

Height

Weight

B. Adverse Reaction

Outcome attributed to adverse reaction(check all that apply)

Date and time of reaction

Date of this report

Describe reaction or problem

Relevant tests

C, SUSPECTED DRUG PRODUCTS(S)

1. Name (give labelled strength & manufacturer, if known).

2. Dose, frequency, & route used

3. Therapy dates(if known, give duration)

4. Indication for use of suspected drug product

5. Reaction abated after use stopped or dose reduced.

Yes

No

Dosen't Apply

6. Lot # (if known)

7. Exp. Date

8. Reaction reappeared after reintroduction

Yes

No

Dosen't Apply

9. Concomitant drugs(name, dose, frequency and route used) and therapy dates

10. Treatment of adverse reaction

D. Reporter

1. Name, address, email, & phone number.

2. Health professional?

Yes

No

3. Occupation

4. Also reported to manufacturer?

Yes

No

E. SUSPECT MEDICAL DEVICE

1. Brand name

2. Type of device

3. Manufacturer name & address

4. Operator of device

Health Professional

Lay user/patient

Other

5. Expiration date

6. If implanted, give date

7. If explanted, give date

Model #

Serial #

Catalog #

Lot #

Other

8. Device available for evaluation? (Do not send)

Yes

No

9. Concomitant medical products and therapy dates (exclude treatment of event)

Request a Refill