(FOM001/HPT/VMS/SOP/001)
Tip: Fields marked with * are mandatory
e.g Nevirapine related rash
e.g E.O.O
If selected, year is mandatory.
(specify)
(Name/ Number)
(What was the patient being treated for before getting the reaction)
When did the reaction start
Please describe the reaction in terms of symptoms
(Other relevant history including pre-existing medical conditions e.g. allergies, smoking, alcohol use, hepatic/ renal dysfunction etc)
Did the reaction resolve after the drug was stopped or when the dose was reduced?
Did the reaction reappear after the drug was reintroduced?
Outcome *
Severity of reaction
Criteria/reason for seriousness
Action taken *
All information collected in this form, identities of the reporter and patient, will remain confidential.
An Adverse Drug Reaction (ADR) is defined as a reaction that is noxious and unintended, and occurs at doses normally used in man for prophylaxis, diagnosis or treatment of a disease, or for modification of physiological function.
especially those where the patient outcome is
All healthcare professionals (clinicians, dentists, nurses, pharmacists, physiotherapists, community health workers etc) are encouraged to report. Patients (or their next of kin) may also report.
All information submitted is handled in strict confidence. The Pharmacy and Poisons Board will assess causality and statistical analysis on each form. Data will periodically be used to review and suggest any interventions that may be required to the Ministry of Health. Data will also be submitted periodically to the Uppsala Monitoring Center - the WHO Collaborating Center for International Drug Monitoring in Sweden
It is important to tick the appropriate box on the top-right corner of the front page to indicate whether the report is an initial (original) report or is a follow-up (subsequent) report.
It is very important that follow-up reports are identified and linked to the original report.
After completing this form, please forward the same to your Pharmacy Department for onward submission, or mail directly, to:
Right click the picture you want to save and open with `Microsoft office picture manager`.
Click on `Edit Pictures` and on the panel that appears on the left, click on `resize`
Select predefined width x height
In the drop down options, select the option `Web Large (640 x 480 px)` and click on ok
Save a copy of the resized photo (using `save as` option) and upload thenew copy
