CONSUMER REPORTING FORM

We are sorry that you or someone that you know has had a reaction to the medicine they were taking or vaccine given. Information you provide when you report side effect can improve the safe use of medicines or vaccines. Please provide your contact details below so we can follow up for further information about your report if necessary. You can report on side effects, drug ineffectiveness, product quality, suspected counterfeit or medical device defect, medication error (i.e. mistake made in the prescription, dosing, dispensing or administration of the medicine).
Please note: all fields marked (*) red are required.
REPORTER DETAILS - About you the person making the report
* First Name
* Second Name
* Telephone
Email
Town / City
Region
WHO EXPERIENCED THE SIDE EFFECT ?
WHO ?
* Name or Initials
* Gender
* Age at time of the side effect
Weight (kg)
SIDE EFFECT
Please complete as many fields as possible.
* What were the signs of the side effect?
* When did the side effect start?
When did the side effect stop?
* Outcome of the side effect
Please select if the side effect resulted in any of the following:
Please Specify
Do you think these side effect occurred as a
result of a mistake made in the prescription, dosing,
dispensing or administration of the medicine or vaccine?
MEDICINE / VACCINE DETAILS – About the medicine/vaccine which might have caused the side effect
* Suspected Medicine / Vaccine
Dosage:
Batch Number
Manufacturer
Expiry Date
Date drug was started
Date you stopped taking the drug
What form did you take your medicine/ vaccine
given to you?
What was/were the reason(s) for taking the
suspected medicine? (Indication)
Where was medicine obtained or vaccine given ?
What action was taken with this medicine
as a result of the side effect(s)
Were you taking any other medicine or herbal products prior to the side effect?
Name of Medicine
Dosage
Date Started
Date Ended
Reasons for use
Other information you think might be important,
including any other medical condition,
any allergies that the person may have,
results of any tests performed etc.
If we need further information to help us
understand the case do we have your
permission to contact you?
Please send e-mail to the National Pharmacovigilance Centre at drug.safety@fda.gov.gh , or call 0244 310 297 for any further assistance regarding drug safety issues.