Transcription of Canada Vigilance Adverse Reaction Reporting Form
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Canada Vigilance Adverse Reaction Reporting Form
Page 1 of 2 Canada Vigilance Adverse Reaction Reporting form Report of suspected Adverse reactions to marketed health products in CanadaPROTECTED WHEN COMPLETED B** HC Pub.: 100251 (April 2010)A program of1. Identifier2. Age3. Sex*4. Height5. WeightYears MonthsMale Femalecm feetkg lbs1. Outcome attributed to Adverse Reaction (Select all that apply)Death:(yyyy-mm-dd)DisabilityLife-t hreateningCongenital malformationHospitalizationRequired intervention to prevent damage/impairmentHospitalization prolongedOther:2. Reaction date (yyyy-mm-dd)3. Report date (yyyy-mm-dd)4. Describe Reaction or problem*5. Relevant tests/laboratory data (including dates (yyyy-mm-dd))6.
Page 1 of 2 Canada Vigilance Adverse Reaction Reporting Form Report of suspected adverse reactions to marketed health products in Canada PROTECTED WHEN COMPLETED – B**
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