Suspected Adverse Drug Reaction Reporting Form

Voluntary reporting by healthcare professionals · Helpline 1800-180-3024

Leave this empty

A Patient information *

Identity stays confidential — initials only, never a full name.

1 · Patient initials * 2 · Age / Date of birth * 3 · Gender * 4 · Weight (kg) · optional Hospital ID — Reg / IPD / OPD / CR No. · optional

B Suspected adverse reaction *

What happened, how serious, and the outcome.

5 · Reaction start date * 6 · Reaction stop date (if resolved) 7 · Describe the event / reaction * 12 · Relevant investigations with dates · optional 13 · Relevant medical / medication history · optional

14 · Seriousness (tick all that apply)

Death Life-threatening Hospitalisation / prolonged Disability Congenital anomaly Other medically important

Leave all unticked if the reaction was non-serious.

15 · Outcome *

Recovered Recovering Not recovered With sequelae Fatal Unknown

C Suspected medication(s) *

At least one suspected drug. Add more as needed (up to 4).

11 · Concomitant medicines (incl. self-medication & herbal) · optional

D Reporter details *

Your identity is confidential — reporting implies no liability.

16 · Name & address * Pin code · optional Email · optional Contact no. · optional Occupation / designation * 17 · Date of report

Patient identity is held in strict confidence. Submission does not imply that any person, manufacturer, or product caused the reaction, and does not replace emergency clinical care. After faculty review, reports follow the official pathway: AMC → NCC-PvPI → WHO-UMC.

Dr. Raj KumarProfessor & Head, Department of Pharmacology — Coordinator

Dr. KamalpreetDeputy Coordinator, Department of Pharmacology

Dr. Harkiratjit Singh BhullarPG Junior Resident, Department of Pharmacology — Designed by

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Report Submitted

Saved and pending faculty review before PvPI submission. The Department of Pharmacology has been notified.

Reference No.

After faculty verification, the data is entered into VigiFlow and forwarded to NCC-PvPI.

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