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


    Reporter Details

    Heath Care Provider

    Manufacturer Information

    Date Received By Manufacturer

    Date Of This Report

    Report Type