Suspect Adverse Reaction Report

Code NO:

Reaction Information

Patient Initials

Date Of Birth

Reaction Onset

Check All Appropriate To Adverse Reaction

Patient Diedinvolved or prolonged inpatient hospitalizationInvolved Persistence or Sighnificant or Disablitty or IncapacityLife ThreateningCongenital AnomalyOther Medically Important Condition

Suspect Drug(S) Information

Did reaction Abate After Stropping Drug?

Did Reaction Reappear After Reintro-Duction?

Therapy Dates

From:
To:

Reporter Details

Heath Care Provider

Manufacturer Information

Date Received By Manufacturer

Date Of This Report

Report Type