PvERS: the Pharmacovigilance Electronic Reporting System: Padrs

This form is meant for members of the public and patients to report medicine side effects, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products.
Health care professionals should register and submit reports after successfull authentication.

DETAILS OF THE PERSON REPORTING

Name of Person Reporting *

County *

Relation

Email Address

Mobile No.*

Your phone number is important for follow up by the
Pharmacy and Poisons Board and to obtain
additional information as well as providing you with the feedback

DETAILS OF THE PATIENT

Patient's Name *

Gender

MaleFemale clear!

Date of Birth

-- clear!

If selected, year is mandatory.

--OR--

Age Group

clear!

Select type of report:

Side Effects Poor Quality Medicine

POOR QUALITY MEDICINE

Select all issues with the medicine/device

The label looks wrong Has unusual material in it The color is changing The smell is unusual The medicine/device is not working The packet or bottle does not seem to be usual or complete

Other wrong thingsAdditional wrong things?

DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION
(Include all medications)

1	Name of Medicine/Vaccine/Device	Manufacturer
	When did you start taking/using the medicine/vaccine/device?	When did you stop taking/using the medicine/vaccine/device? (dd-mm-yyyy)
	Expiry date of the medicine/vaccine/device	Where did you buy the medicine/vaccine/device?
For additional medicines/vaccines/devices, click

OUTCOME DETAILS

Outcome

Recovered/resolvedRecovering/resolvingRecovered/resolved with sequelaeNot recovered/not resolvedDeathUnknown clear!

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

#	File	Text Description

If we need further information to help us understand the case do we have your permission to contact you?

clear!

Please solve the riddle

ten + 0 =

This form is meant for members of the public and patients to report medicine side effects, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products.
Health care professionals should register and submit reports after successfull authentication.

DETAILS OF THE PERSON REPORTING

DETAILS OF THE PATIENT

--OR--

SIDE EFFECT

Select all side effects experienced

POOR QUALITY MEDICINE

Select all issues with the medicine/device

DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION
(Include all medications)

OUTCOME DETAILS

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

This form is meant for members of the public and patients to report medicine side effects, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products. Health care professionals should register and submit reports after successfull authentication.

DETAILS OF THE PERSON REPORTING

DETAILS OF THE PATIENT

--OR--

SIDE EFFECT

Select all side effects experienced

POOR QUALITY MEDICINE

Select all issues with the medicine/device

DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION (Include all medications)

OUTCOME DETAILS

Do you have pictures or documents that you would like to send to PPB? click on the button to add them:

This form is meant for members of the public and patients to report medicine side effects, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products.
Health care professionals should register and submit reports after successfull authentication.

DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION
(Include all medications)