Reporting Form for Suspected Adverse Reactions

National Pharmacovigilance Program for ASU & H Drugs

Personal information will be kept confidential.
All suspected reactions are to be reported with relevant details.

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1. Patient / consumer identification (please complete or tick boxes below as appropriate)

2. Description of the suspected Adverse Reactions

3. Whether the patient is suffering with any chronic disorders?

6. Name of all ASU & H drugs used by the patient during the period of one month

7. Name of other drugs used by the patient during the period of one month

8. Details of the drug suspected to cause ADR

9. Management provided / taken for suspected adverse reaction

10. Please indicate outcome of the suspected adverse reaction (tick appropriate)

11. Any abnormal findings of relevant laboratory investigations related to the episode done pre and post episode of ADR

12. Particulars of ADR Reporter

Fill the above reporting form and submit
Send us filled form to the below mentioned address

Postal Address:
The Coordinator, National Pharmacovigilance Coordination Centre (NPvCC)
All India Institute of Ayurveda (AIIA), Mathura Road, Gautam Puri,
Sarita Vihar, New Delhi – 110076


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Print any of the downloaded form file and send us the manually filled form to our postal address

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