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Country of occurrence

PATIENT OR HEALTH CARE PROFESSIONAL?

Who notifies?

PRODUCT

Unauthorized product

Vaccination Date

BATCH Nº

Administration Route

DOSE ADMINISTERED

EXPIRATION DATE

Description of the case (describe the sequence of the events in detail)

SYMPTOMS OBSERVED

INITIAL DATE OF THE SYMPTOMS OBSERVED

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END DATE OF THE SYMPTOMS OBSERVED OR ONGOING

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SYMPTOMS ONGOING

Initial date of the clinical signs

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End date of the clinical signs or ongoing

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Clinical signs ongoing

Who reports the case

Animal data

Number of animal treated

Number of animal reacted

Number of dead animals

SERIOUSNESS

OUTCOME

Any relevant additional information

NAME (Reporter)

CITY/TOWN (Reporter)

Email (Reporter)

Gender (Patient)

NAME (patient)

HEIGHT (patient)

WEIGHT (patient)

AGE (patient)

ADDRESS (patient)

CITY/TOWN (Patient)

ZIP/POSTAL CODE (Patient)

COUNTRY (patient)

PHONE (patient)

Email (Patient)

PROFESSION (health care professional)

NAME (health care professional)

SURNAME (health care professional)

ADDRESS (Health Care Professional)

CITY/TOWN (Health Care Professional)

TELEPHONE (Health care professional)

COUNTRY (Health care professional)

Email (Health Care Professional)

Gender (Patient)

Initials (Patient)

Height (Patient)

Weight (Patient)

Age (Patient)

Email (Patient)

NAME (Health Care Professional)

CITY/TOWN (Health Care Professional)

Email (Health Care Professional)

Name

Surname

Name

We recommend that you fill out this field.

Surname

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Country

Email address

Mobile Phone

Identity card number (DNI, NIE...)

Name (people involved)

Surname (people involved)

Department or area (people involved)

Description of the facts

Approximate date of events

Do the facts affect or can they affect third parties?

Please, indicate to whom

To any movable and/or immovable property?

Have these facts been reported previously?

Please, indicate an approximate date:

Please, indicate to whom

I declare I have not strayed from the truth, that the data and facts are true and complete, and that this communication is made in good faith.

This form allows anyone to report a behaviour or fact to the HIPRA Compliance department.

Organisation

Position/Type of professional

Attachment

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