Materiovigilance – pharmaadvance.in

Patient Information *

Patient identity is held in strict confidence — no full name required

1. Patient Initials *

2. Age or Date of Birth *

3. Gender *

M F Other

4. Weight (kg)

Reg. No. / IPD No. / OPD No. / CR No.

Suspected Medical Device *

Include all identifiers available — batch/lot or serial number is essential

5. Device Name / Generic Name *

6. Brand / Trade Name

7. Model Number

8. Catalogue / Product Code

9. Batch / Lot Number *

10. Serial Number

11. Expiry Date

12. Device Type *

13. Manufacturer Name *

Manufacturer Address / Country

14. Device Usage Dates

Date of Use / Procedure

Date of Implantation (if implant)

Date of Explantation (if removed)

15. Single-use Device?

Yes No Unknown

Was it reused?

Yes No Unknown

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Upload Documents & Evidence

Device label · Photos · Investigation reports · Discharge summary · Operative notes

🏷 Device label / package 📷 Device photos 📋 Operative notes 🧪 Lab / pathology reports 🩻 Imaging reports 📄 Discharge summary

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Click to browse files or drag & drop here

JPG · PNG · PDF · Max 10 MB per file · Up to 5 files

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Additional Information

Any other information relevant to this materiovigilance report

Reporter Details *

Reporter identity is confidential — submission does not imply legal liability

24. Name & Address *

Pin Code

Contact No.

Occupation / Designation *

25. Date of this report

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Patient identity is held in strict confidence. Submission does not constitute an admission that medical personnel or manufacturer caused the event. Reports are forwarded to AMC → CDSCO MvPI National Coordination Centre.

Also report directly: mvpi@cdsco.nic.in · CDSCO: cdsco.gov.in

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Materiovigilance Report Submitted Successfully

Your report is saved and pending faculty review before CDSCO MvPI submission.

The Pharmacology Department has been notified by email.
After faculty verification, the report will be forwarded to the CDSCO MvPI portal.

Suspected Medical Device Adverse Event Reporting Form

Materiovigilance Report Submitted Successfully