For reporting of adverse events/side effects and/or product quality complaints

New Form Existing Form

FAQ

Session Idle: seconds

Status: New

Unique Id: UID23203340710202514

Instruction

Reporter's Information

Reporter Type*: Health care professional Patient Others Name/Initial of the Reporter *: Country*:

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Mobile Number: Email*:

Patient's Information

Name/Initial* Gender* Female Male

Date of Birth

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Age*

Years

Months

Days

Suspect Product Information

Select the brand name of the Biocon Biologics product which the patient has used. If Brand name is not available in the dropdown list or with the patient, select "Others" and mention Brand/Generic name of the medicine.

Brand Name*:

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Brand/Generic Name:

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Batch No/Lot No Country where medicinal product was purchased

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Duration of use: From

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or if exact dates not known approx duration of use.

select

Event Information

Event Type

Adverse Event/Side effect Product problem others

Event Onset Date

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Country of occurence

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Please describe the adverse event/product complaint (if you are a health care professional include event term/diagnosis of the adverse event/side effect)*

What is the outcome of the event condition

Recovered/Resolved Not recovered/Not resolved Recovering/Resolving
Recovered/Resolved with sequelae Unknown Death/Fatal

Do you consider the adverse event/side effect as serious? Yes No

SAVE AS DRAFT SUBMIT