Name * Email * Phone * Seriousness DeathLife-threateningCongenital anomalyRequires inpatient hospitalisation or prolongation of existing hospitalizationResults in persistent or significant disability or incapacityRequired intervention to prevent permanent injury Other (Specify) Report Source PhysicianPharmacistNursePatient Other (Specify) Product Type DrugVaccineHerbal ProductsCosmeticsDiagnostics Other (Specify) Action Taken Drug withdrawDose reducedFrequency reducedDose increasedTherapy changedRequired treatment with prescription medicationNo action was taken Current patient condition RecoveredRecoveringNo ImprovementUnknown Other (Specify) Does the event happened because of Quality Issue YesNo Does the product stored according to the instructions YesNo Quality observation Physical, chemical or microbial changesPresence of ParticlesSuspected contaminationNo effectPackagingLabeling problems (caused by printing errors / omissions)Product confusion (caused by name, labeling, design or packaging) Other (Specify) Sample Availability YesNo Did the physician or pharmacist had been informed YesNoI don’t Know Did the physician or pharmacist submit ADR report YesNoI don’t Know Can we get more information from the responsible physician YesNoI don’t Know ← → x ×