MINISTRY OF PUBLIC HEALTH CBETWEEN NATIONAL DE PHARMACOVIGILANCE Medical Drug Agency of Madagascar Notification Sheet listing the adverse effects of medicines/vaccines Health Training Place of Department (if establishment Weight Patient's First name and Surname Date of birth Age Sex applicable) Height (cm) (kg) ...../...../.... ( ) _ F M _ Pregnant? Yes No Not known If yes, date of last period: / / Address: City/village: Description of the adverse effect: Date started / / Date stopped / / time day . month year Period of appearance: (add an additional sheet if necessary) _ _ _ Stoppage of the medicine? Yes No Yes, Disappearance of the adverse effect? Yes No _ .If _ _ _ _ Re-administration of the medicine? Yes No If yes, reappearance of the adverse effect? Yes No _ - Corrective treatment Yes, which one? No Medicines / other suspected and associated health products (place an next to the suspected medicine) A (add an additional sheet if necessary) Posology Date taken C.D.S. Indication / reason Expiry and means of Trade name / manufacturer Batch No (active substance) for treatment date Start End administration VACCINES RECEIVED Place of vaccination Number Sector Suspected vaccine Batch No Means of Administration taken Public Private Development of adverse effect Seriousness of the adverse effect _ Cured without sequelae _Vital _ _ prognosis Not known Hospitalisation . _ Cured with sequelae _Death _ Permanent disability . _ Not yet cured _ Extension of hospitalisation _ Death _ Congenital malformation Associated risk factors pertinent medical history, previous reaction to the medicine, (tobacco, alcohol etc.), laboratory examinations, comments (add an additional sheet if necessary) . .. .. Reporter's name Professional category Telephone /Fax/ Email Date / / Signature: THIS INFORMATION IS CONFIDENTIAL
MINISTRY OF PUBLIC HEALTH CBETWEEN NATIONAL DE PHARMACOVIGILANCE Medical Drug Agency of Madagascar Notification Sheet listing the adverse effects of medicines/vaccines Health Training Place of establishment Department (if applicable) Patient's First name and Surname Date of birth Age Sex Weight (kg) Height (cm) ...../...../.... ( ) _ F M Pregnant? Yes No _ Not known If yes, date of last period: / / Address: City/village: Description of the adverse effect: Date started / / Date stopped / / Period of appearance: time day . month year (add an additional sheet if necessary) Stoppage of the medicine? _ Yes _ No .If Yes, Disappearance of the adverse effect? _ Yes _ No Re-administration of the medicine? _ Yes _ No If yes, reappearance of the adverse effect? _ Yes _ No Corrective treatment _ Yes, which one? - No Medicines / other suspected and associated health products (place an A next to the suspected medicine) (add an additional sheet if necessary) Trade name / manufacturer C.D.S. (active substance) Posology and means of administration Date taken Indication / reason for treatment Expiry date Batch No Start End VACCINES RECEIVED Suspected vaccine Batch No Means of Administration Number taken Place of vaccination Sector Public Private Development of adverse effect Seriousness of the adverse effect _ Cured without sequelae _ Cured with sequelae _ Not yet cured _ Death _ Not known . _ Hospitalisation _ Permanent disability _ Extension of hospitalisation _ Congenital malformation _Vital prognosis . _Death Associated risk factors (tobacco, alcohol etc.), pertinent medical history, previous reaction to the medicine, laboratory examinations, comments (add an additional sheet if necessary) . .. .. Reporter's name Professional category Telephone /Fax/ Email Date / / Signature: THIS INFORMATION IS CONFIDENTIAL