Get Suspected Adverse Drug Reaction Reporting Form For Voluntary Reporting Of Adverse Drug Reactions By

Filling out the Suspected Adverse Drug Reaction Reporting Form is a crucial step in reporting adverse reactions to medications. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to effectively fill out the reporting form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering patient information in section A. Include the patient's initials, age at the time of the event, date of birth, sex, and weight. Additionally, provide relevant tests or laboratory data with dates, and detail any pre-existing medical conditions that could be pertinent.
3. In section B, fill out the suspected adverse reaction details. Record the date the reaction started and, if applicable, the date of recovery. Describe the reaction or problem experienced and indicate the seriousness of the reaction by selecting the appropriate option.
4. Continue in section B by providing the outcome of the reaction. Choose from options such as fatal, continuing, recovering, or recovered, and provide any additional information as necessary.
5. Move on to section C, where you will document the suspected medication(s). Include details about the name of the medication, manufacturer, batch number, expiration date, dosage, and route of administration.
6. Indicate the frequency of use and the therapy dates. If possible, provide the reason for the prescribed medication.
7. Answer questions regarding the reaction’s response to the medication, such as whether the reaction abated after stopping the drug and if it reappeared upon reintroduction.
8. Include a list of any concomitant medical products or self-medications that were taken at the same time, excluding those used to treat the adverse reaction.
9. In section D, provide reporter information. Include your name, professional address, pin code, email, telephone number, and occupation.
10. Complete the causality assessment section and provide your signature and date of the report to finalize your submission.
11. After completing the form, you can save changes, download, print, or share the form as needed.

Submit your report online to contribute to our understanding of adverse drug reactions.