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Adverse Event Form

Product Safety

Adverse Event Form

B. SUSPECTED DRUG(S)/VACCINE(S)/ALTERNATIVE MEDICINE(S) (use additional pages if necessary):
C. SUSPECTED REACTION(S) (use additional pages if necessary):
D. OTHER CONCOMITANT DRUG(S)/VACCINE(S)/ALTERNATIVE MEDICINE(S) (use additional pages if necessary)
E. SUSPECTED MEDICAL DEVICE(S) fill this area for suspected Device only (use additional pages if necessary):
F. REPORTER DETAILS

Additional Form

B. SUSPECTED DRUG(S)/VACCINE(S)/ALTERNATIVE MEDICINE(S) (continued):
C. SUSPECTED REACTION(S) (continued):
D. OTHER CONCOMITANT DRUG(S)/VACCINE(S)/ALTERNATIVE MEDICINE(S) (continued)
E. SUSPECTED MEDICAL DEVICE(S) (continued):