Form 2 - VIOLA

REPORT FORM
ON ADVERSE REACTION TO MEDICINAL PRODUCT, VACCINE, TUBERCULIN AND/OR LACK OF EFFICACY OF MEDICINAL PRODUCT (MP) AND/OR ADVERSE EVENT FOLLOWING IMMUNIZATION (AEFI)/TUBERCULIN DIAGNOSTICS TO BE SUBMITTED BY PATIENT AND/OR HIS/HER REPRESENTATIVE

1. Patient information

First namePatronymicLast nameAddressTel./fax

2. Information about the suspected MP, vaccine, tuberculin

Trade namePresentationManufacturer

3. Information on prescribing the suspected MP, vaccine, tuberculin

Suspected MP, vaccine, tuberculin were prescribed to patient by doctor-yesnoPatient used suspected MP, vaccine, tuberculin without medical prescription-yesno

4. Describe manifestations of adverse reaction to MP, vaccine, tuberculin and/or AEFI/tuberculin diagnostics and/or indicate the MP lack of efficacy

5. Information about reporter

First namePatronymicLast nameAddressTel./fax

6. Information about doctor, health facility and address of patient who experienced adverse reaction to MP, vaccine, tuberculin and/or MP lack of efficacy and/or AEFI/tuberculin diagnostics

First namePatronymicLast nameAddress of health facilityTel./faxName of health facility, where doctor worksPatient’s address

REPORT FORM ON ADVERSE REACTION TO MEDICINAL PRODUCT, VACCINE, TUBERCULIN AND/OR LACK OF EFFICACY OF MEDICINAL PRODUCT (MP) AND/OR ADVERSE EVENT FOLLOWING IMMUNIZATION (AEFI)/TUBERCULIN DIAGNOSTICS TO BE SUBMITTED BY PATIENT AND/OR HIS/HER REPRESENTATIVE

REPORT FORM
ON ADVERSE REACTION TO MEDICINAL PRODUCT, VACCINE, TUBERCULIN AND/OR LACK OF EFFICACY OF MEDICINAL PRODUCT (MP) AND/OR ADVERSE EVENT FOLLOWING IMMUNIZATION (AEFI)/TUBERCULIN DIAGNOSTICS TO BE SUBMITTED BY PATIENT AND/OR HIS/HER REPRESENTATIVE