Safety Related Form Report For Suspect Safety-Related Events Adverse Events / unwanted reactions Interactions Overdose Abuse / misuse Medication error Lack of efficacy Off label use Occupational exposure Transmission of infectious agent Use during pregnancy / breastfeeding SUSPECT PRODUCT*BATCHEXP. DATEREPORTER (NAME)*Is the reporter health professional? Yes No DATEE-MAIL PHONEAddress / address of the establishment (for health professionals)*EVENT: Description what happened and when.PATIENT: Please provide at least one of the information mentioned below (age, gender, initials).AgeGenderInitialsSOURCEOTHER RELEVANT INFORMATIONPhoneThis field is for validation purposes and should be left unchanged.
