PvERS: the Pharmacovigilance Electronic Reporting System: Padrs

This form is meant for members of the public and patients to report adverse drug reactions, 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 *

Relation

County *

Email Address

--OR--

Mobile No.

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:

Adverse Reaction 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

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

#	File	Text Description

Please solve the riddle

nine - one =

This form is meant for members of the public and patients to report adverse drug reactions, 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)

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 adverse drug reactions, 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)

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 adverse drug reactions, 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)