PViMS MicroService: Web and mobile based Pharmacovigilance Monitoring System

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Adverse Event Report For *

Drug

Vaccine

A. PATIENT INFORMATION

Age Not Available

B. SUSPECTED ADVERSE EVENT INFORMATION

Type of event (Multiple select)

Specify

Describe event including relevant tests and laboratory results *

Event Start date *

N/A

Event Stopped date *

N/A

Was the adverse event treated?

If yes, please specify

Action taken after reaction

Did reaction subside after stopping / reducing the dose of the suspected product?

Adverse event (AE) name - Multiple select *

If other, please specify

Did reaction appear after reintroducing the suspected product?

Seriousness of the adverse event

If serious, please select

Outcomes attributed to the adverse event *

If fatal, please select date of death

Other relevant history (pre-existing medical history) - Multiple select

Specify

C. SUSPECTED DRUG/VACCINE INFORMATION

Brand/ Trade Name

Generic Name with strength *

Indication

Medication Start Date/Vaccination Date *

N/A

End Date/Vaccination Time *

N/A

Dosage Form

Frequency (Daily Dosage)

Batch/Lot number

Manufacturer

Diluent Information for vaccine

CONCOMITANT MEDICINE/VACCINE INFORMATION MEDICINE/VACCINE Not Available

D. REPORTER INFORMATION

Source of reporting *

Reporting type *

Initial Report ID

Reporter Name *

Full Address

Phone *

Occupation *

Date of this report submission *

Organization *

Company *

Upload Signature

Document Upload (Only supported PDF & max upload file 4MB)

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