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YELLOW CARD
Adverse Event Report For
*
Drug
Vaccine
A. PATIENT INFORMATION
Age Not Available
Select Gender
*
Male
Female
Other
Select pregnancy status
Yes
No
Unknown
Not applicable
Select Division
Barishal Division
Chattogram Division
Dhaka Division
Khulna Division
Mymensingh Division
Rajshahi Division
Rangpur Division
Sylhet Division
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Select District
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Select Upazila
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B. SUSPECTED ADVERSE EVENT INFORMATION
Type of event (Multiple select)
Select type of event
Adverse drug reaction
Adverse event following immunization
Medication error
Vaccination error
Product quality problem
Others (Please specify)
Specify
Describe event including relevant tests and laboratory results
*
Event Start date
*
N/A
Event Stopped date
*
N/A
Was the adverse event treated?
Select status
Yes
No
Not available
If yes, please specify
Action taken after reaction
Select reaction
Dose stopped
Dose reduced
No Action Taken
Did reaction subside after stopping / reducing the dose of the suspected product?
Select reaction subside info
Yes
No
Not Applicable
Unknown Subside
Adverse event (AE) name - Multiple select
*
Fever
Muscle Pain
Headache
Nausea
Vomiting
Caughing
Breathing Difficulty
Back Pain
Joint Pain
Abscess
Isomnia
High BP
Low BP
Increased heart rate
Heart Failure
Miocardial Infection
Anaphylasis
Unconcious
Other
If other, please specify
Did reaction appear after reintroducing the suspected product?
Select reaction status
Yes
No
Not Applicable
Seriousness of the adverse event
Select seriousness status
Serious
Not serious
If serious, please select
Select seriousness
Hospitalization or prolongation of hospitalization
Disability or permanent damage
Congenital anomaly / birth defect
Life threatening
Death
Other Medically important
Outcomes attributed to the adverse event
*
Select outcomes
Recovered
Recovered/resolved with sequela
Not recovered
Unknown Outcome
Fatal (date of death)
If fatal, please select date of death
Other relevant history (pre-existing medical history) - Multiple select
Select relevant history
Hypersensitivity
Allergies
Hypertension
Liver or kidney problems
Smoking
Alcohol
Diabetes
Others
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
Add
Remove
D. REPORTER INFORMATION
Source of reporting
*
Select Source of reporting
Health Facilities (Hospital/Clinic)
Marketing authorization holder
Public Health Programme (PHP)
Patient/ Consumer/ Public
Others
Reporting type
*
Select Reporting type
Initial report
Follow-up report
Initial Report ID
Reporter Name
*
Full Address
Email
Phone
*
Occupation
*
Choose Occupation
Physician
Pharmacist
Consumer/ Patient
Other Health Professional
Other Non-Health Professional/ MAH
Date of this report submission
*
Organization
*
Choose Organization
100 bed Burn Unit at DMCH
250 bed District Hospital, Cox’s Bazar
Ad-din Barrister Rafiq ul Huq Hospital, Dhaka
Al-Helal Specialized Hospital Ltd., Dhaka
Anwar Khan Modern Medical College Hospital
Armed Forces Medical College & Hospital
Asgar Ali Hospital, Dhaka
Bagerhat District Hospital
Bandarban District Hospital
Bangabandhu Sheikh Mujib Medical College Hospital, Faridpur
Bangabandhu Sheikh Mujib Medical University (BSMMU)
Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM)
Bangladesh Medical College & Hospital, Dhanmondi
Barguna District Hospital
Barisal General Hospital
BGB Hospital
Bhola District Hospital
Bogra 250 bed Mohammad Ali District Hospital
Brahmanbaria 250 Bed District Sadar Hospital
Central Police Hospital
Chandpur 250 Bed General Hospital
Chapai Nababganj District Hospital
Chittagong 250 Bed General Hospital
Chittagong Medical College Hospital
Chuadanga District Hospital
Colonel Malek Medical College Hospital
Combined Military Hospital (CMH), Dhaka
Comilla General Hospital
Cox's Bazar Medical College Hospital
Cumilla Medical College Hospital
Delta Medical College & Hospital
Dhaka Central International Medical College & Hospital
Dhaka Medical College Hospital
Dhaka Shishu Hospital
Dinajpur 250 bed General Hospital
Evercare Hospitals Ltd. Dhaka
Faridpur General Hospital
Feni 250 Bed District Sadar Hospital
Gaibandha 200 bed Hospital
Gonoshasthaya Nagar Hospital, Dhanmondi, Dhaka
Gopalganj 250 bed General Hospital
Government Kormochary Hospital, Fulbaria, Dhaka
Green Life Medical College & Hospital
Habiganj District Hospital
Holy Family Red Crescent Medical College (RCMCH)
Ibn Sina Medical College and Hospital, Dhaka
Ibrahim Iqbal Memorial Hospital, Chattogram
Institute of Child and Mother Health, Matuail
International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR’B)
Jamalpur 250 Beded General Hospital
Jashore Medical College Hospital
Jessore 250 bed General Hospital
Jhalokathi District Hospital
Jhenaidah District Hospital
Joypurhat District Hospital (150 Bedded)
Khagrachari District Hospital
Khulna 250 Bed General Hospital, Khulna
Khulna Medical College Hospital
Kishoreganj 250 Bed District Sadar Hospital
Kurigram District Hospital
Kurmitola 500 Bed General Hospital
Kushtia 250 bed General Hospital
Kushtia Medical College Hospital
Lab Aid Hospital
Lab Aid Hospital, Dhanmondi
Lakshmipur District Hospital
Lalmonirhat District Hospital
M Abdur Rahim Medical College Hospital
Madaripur District Hospital
Magura District Hospital
Magura Medical College Hospital
Manikganj 250 Bed District Hospital
Meherpur 250 bed District Hospital
Moulvibazar 250 bed District Sadar Hospital
Mugda Medical College Hospital, Dhaka
Munshiganj District Hospital
Mymensingh Medical College Hospital
Naogaon District Hospital
Narail District Hospital
Narayanganj 300 Bed Hospital
Narayanganj General (Victoria) Hospital
Narsingdi District Hospital
National Heart Foundation Hospital and Research Institute
National Inst. of Cancer Research Hospital NICRH
National Institute of Cardio Vascular Disease (NICVD)
National Institute of Diseases of the Chest and Hospital (NIDCH)
National Institute of ENT
National Institute of Kidney Disease and Urology (NIKDU)
National Institute Of Mental Health (NIMH)
National Institute of Neuroscience (NINS)
National Institute of Ophthalmology & Hospital (NIO)
National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR)
National Medical College and Hospital, Dhaka
Natore District Hospital
Netrokona District Hospital
Nilphamari District Hospital
Noakhali 250 Bed General Hospital
Noakhali Medical College Hospital
OGSB Hospital and Institute of Reproductive & Child Health, Dhaka
Others (Facility)
Pabna 250 bed General Hospital
Pabna Medical College Hospital
Pabna Mental Hospital
Panchagarh District Hospital
Patuakhali 250 bed Sadar Hospital
Pirojpur District Hospital
Popular Medical college & Hospital
Rajbari District Hospital
Rajshahi Medical College Hospital
Rangamati General Hospital
Rangpur Medical College Hospital
Satkhira District Hospital
Satkhira Medical College Hospital
Shahabuddin Medical College and Hospital
Shaheed M Monsur Ali Medical College Hospital
Shaheed Sheikh Abu Naser Specialized Hospital
Shaheed Suhrawardy Medical College Hospital
Shaheed Taj Uddin Ahmad Medical College Hospital
Shaheed Ziaur Rahman Medical College Hospital, Bogra
Shahid Syed Nazrul Islam Medical College Hospital
Shariatpur District Hospital
Sheikh Hasina Medical College Hospital, Jamalpur
Sheikh Hasina Medical College Hospital, Tangail
Sheikh Hasina National Institute of Burn and Plastic Surgery, Dhaka
Sheikh Russel National Gastroliver Institute & Hospital
Sheikh Sayera Khatun Medical College Hospital
Sher-e-bangla Medical College Hospital
Sherpur District Hospital
Sir Salimullah Medical College Hospital
Sirajganj General Hospital
Square Hospitals Ltd
Sunamganj 250 bed District Sadar Hospital
Sylhet MAG Osmani Medical College Hospital
Sylhet Shahid Shamsuddin Ahmed District Hospital
Tangail 250 Bed District Hospital
Thakurgaon District Hospital
United Hospitals Ltd
WMCH, Uttara,Dhaka
Z H Sikder Women's Medical College & Hospital
Company
*
Choose Company
ACI HealthCare Limited
Active Fine Chemicals Ltd.
Ad-din Pharmaceuticals Ltd.
Adova Pharmaceuticals Ltd.
Advanced Chemical Industries Limited
Amulet Pharmaceuticals Ltd.
APC Pharma Limited
Apex Pharma Ltd.
Apollo Pharmaceutical Laboratories Ltd.
Arges Life Science Ltd.
Aristopharma Limited
Aristopharma Limited, Gazipur
Army Pharma Limited
Asiatic Laboratories Ltd.
Astra Biopharmaceuticals Ltd.
Avarox Pharmaceuticals Ltd.
Aztec Pharmaceuticals Ltd.
Bangladesh Antibiotic Industries Limited
Beacon Cephalosporin Ltd.,
Beacon Pharmaceuticals PLC
Belsen Pharmaceuticals Ltd.
Bengal Drugs & Chemical Works Pharm. Ltd.
Bengal Remedies Ltd.
Benham Pharmaceuticals Ltd.
Beximco Pharmaceuticals Ltd.
Beximco Pharmaceuticals Ltd., Kaliakoir
Bexter Pharmaceuticals
Concord Pharmaceuticals Ltd.
Cosmic Pharma Ltd.
Cosmo Pharma Laboratories Ltd.
DBL Pharmaceuticals Limited
Decent Pharma Laboratories Ltd.
Delta Pharma Limited
Desh Pharmaceuticals Ltd.
Dider Pharma Ltd.,
Doctor Tims Pharmaceuticals Ltd.
Doctor's Chemicals Works Ltd.
Drug International Ltd.
Drug International Ltd., Gopalpur
Drug International Ltd., Squib Road
EDCL (Bogra)
EDCL (Dhaka)
Edruc Ltd.
EMCS Pharma Limited
Eon Pharmaceuticals Ltd.
Eskayef Pharmaceuticals Ltd. Chandana, Gazipur
Eskayef Pharmaceuticals Ltd. Mirpur.
Eskayef Pharmaceuticals Ltd., Narayanganj
Genvio Pharma Ltd.
Get Well Limited
Global Capsules Ltd.
Global Capsules Ltd., Gelatin Division
Global Heavy Chemicals Ltd.
Globe Pharmaceuticals Ltd.
Globex Pharmaceuticals Ltd.
Gonoshasthaya Basic Chemical Ltd.
Gonoshasthaya Pharmaceuticals Ltd.
Goodman Pharmaceuticals Ltd
Greenland Pharmaceuticals Ltd.
Guardian Healthcare Ltd.
Healthcare Pharmaceuticals Ltd.
Hudson Pharmaceuticals Ltd.
Ibn Sina Pharmaceutical Ind. Ltd.
Incepta Pharmaceuticals Ltd.
Incepta Pharmaceuticals Ltd. (Dhamrai Unit)
Incepta Pharmaceuticals Ltd., Chemical Division
Incepta Pharmaceuticals Ltd., Vaccine Division
Indo-Bangla Pharmaceuticals Ltd.
Islam Oxygen (Pvt) Ltd.
Jayson Pharmaceuticals Ltd.
Libra Infusion Limited
Linde Bangladesh Limited
Maks Drugs Ltd.
Marksman Pharmaceutical Ltd.
Medicon Pharmaceuticals Ltd.
Medimet Pharmaceuticals Ltd.
MedRx Life Science Ltd.
Millat Pharmaceuticals Ltd.
Modern Pharmaceuticals Ltd.
Momtaz Pharmaceuticals Ltd.
Monicopharma Limited
MSF Pharmaceuticals Ltd.,
MST Pharma and Healthcare Ltd.
Mundipharma (Bangladesh) Pvt. Ltd.
Mystic Pharmaceuticals Ltd.
Naafco Pharma Ltd.
National Drug Company Ltd.
National Laboratories Ltd.
Navana Pharmaceuticals Ltd.
Newtec Pharmaceuticals Ltd.
Nip Chemicals And Pharmaceuticals Ltd.
Novartis (Bangladesh) Limited
One Pharma Ltd.
Opsonin Bulk Drugs Ltd.
Opsonin Pharma Limited
Orion Infusion Ltd.
Orion Pharma Ltd.
OSL Pharma Ltd.
Others (MAH)
Oyster Pharmaceuticals Ltd.
Pacific Pharmaceuticals Ltd.
Peoples Pharma Ltd.
Pharmacil Ltd.
Pharmasia Ltd.
Pharmatek Chemicals Ltd.
Pharmik Laboratories Ltd.
Physic Pharmaceuticals Ltd.,
Popular Pharmaceuticals Ltd.
Premier Pharmaceuticals Ltd.
Prime Pharmaceuticals Ltd.
Pristine Chem Limited
Pristine Pharmaceuticals
Purbadesh Chemists Ltd.,
Quality Pharmaceuticals (Pvt) Ltd.
Radiant Pharmaceuticals Ltd.
Renata Ltd., Bhaluka
Rephco Pharmaceuticals Ltd.
RN Pharmaceuticals
Roche Bangladesh Ltd
Royal Pharmaceuticals Ltd.
S. N. Pharmaceuticals Ltd.
Sanofi Bangladesh Ltd.
Save Pharmaceuticals Ltd.
Seba Laboratories Ltd.
Sharif Pharmaceuticals Ltd.
Shinil Pharma Limited
Silco Pharmaceuticlas Ltd.
Silva Pharmaceuticals Ltd.
SMC Enterprise Limited
Sodical Chemical Ltd.
Somatec Pharmaceuticals Ltd.
Spectra International Ltd.,
Spectra Oxygen Limited
Square Cephalosporins Ltd.
Square Formulations Ltd.
Square Lifesciences Limited, Pabna
Square Pharmaceuticals PLC, (Chemical Division)
Square Pharmaceuticals PLC, Gazipur
Square Pharmaceuticals PLC, Pabna
Techno Drugs Ltd., Gazipur
The ACME Laboratories Ltd.
The White Horse Pharmaceuticals Ltd.
UNIDO Pharmaceuticals Ltd.
Unimed Unihealth Pharmaceuticals Ltd.
Union Oxygen Limited
Union Pharmaceuticals Ltd.
Unique Pharmaceutical Ltd.
United Chemicals & Pharmaceuticals Ltd.
Veritas Pharmaceuticals Ltd.
Vion Pharmaceuticals (Veterinary)
Virgo Pharmaceuticals Ltd.
Vision Drugs Limited (Veterinary)
World API Chemical Industry Ltd.
Zenith Pharmaceuticals Ltd.
Zhaofeng Gelating Limited
Ziska Pharmaceuticals Ltd.
Other organization/company unit
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