Children’s Health Queensland Report of locally occurring adverse event Protocol no. insert number HREC reference number: insert number Protocol title: insert title of project Patient (Initials or Record No. Date of Birth dd / mm / yyyy only) Gender M F Report Initial Follow up Date of onset of reaction dd / mm / yyyy Severity Yes No Serious Life threatening or fatal Expected Is causality suspected? Yes No Almost certainly: Probably: Possibly: Unlikely: Adverse reaction description: All drug therapy/vaccines prior to Daily Date Date reaction dosage begun stopped Reason for use
Children’s Health Queensland Report of locally occurring adverse event Protocol no. insert number HREC reference number: insert number Protocol title: insert title of project Patient (Initials or Record No. only) Date of Birth dd / mm / yyyy Gender M F Report Initial Follow up Date of onset of reaction dd / mm / yyyy Severity Yes No Serious Life threatening or fatal Expected Is causality suspected? Yes No Almost certainly: Probably: Possibly: Unlikely: Adverse reaction description: All drug therapy/vaccines prior to reaction Daily dosage Date begun Date stopped Reason for use
sae-local.docx