VigiCarib Reporting Form

This form is intended for persons living in the Caribbean Community (CARICOM) or in other CARPHA Member States, who would like to submit a report of an unexpected or serious adverse reaction that occurred with you or with someone you are a guardian for, after receiving a medicine. Completion of this form is voluntary, and the information is sent to the country's Ministry of Health for follow up according to national policies. The patient's name does not need to be stated (initials may be used), but the name and contact of the reporter will be needed.

If the event being reported has not been medically confirmed, the person who is affected is advised to seek medical care or assistance from a health care professional. The health professional may submit the report using the form located here, as an alternative: https://form.jotform.co/72934157245864.

The report will be considered as 'preliminary' or 'unconfirmed', and it will be sent to the ministry of health for verification, as per national policies, procedures and criteria. CARPHA is not responsible for case follow-up at the local level.

We understand that you may not have all the details at the time of making the report, but the most important details we need are:

a way to identify the patient (e.g. initials, alias),
the age and sex of patient,
a description of the reaction / event,
the name of the medicine,
the date the medicine was used,
the date reaction started,
the name and contact for the reporter, and
the country where you got the medicine.

Of course, if you have more details (like other conditions the person has, if they recovered), please add them. Where you do not have the information for a field, you can state 'not available' or skip to the next field.

The Caribbean Public Health Agency is committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. Information collected is subject to CARPHA's privacy policy. See the full policy at: https://carpha.org/Privacy.

If you have any questions about this form, you may email us at vigicarib@carpha.org.

Today's Date

DayMonthYear

Name of medicine*

E.g. Acetaminophen

Brand name (where applicable)

E.g. Panadol

Dosage form

Strength (include units)

E.g. 800mg; 5mg/mL

Manufacturer name

Batch / Lot Number, if available

Expiry Date, if available (mm-yyyy)

Description of Adverse Reaction*

Patient Initials or Alias, or Identifier*

Patient Sex

Patient age at time of event (number only)

Age unit

Race / Ethnicity

How much and how often was the medicine used, e.g. one tablet twice a day

Please state what condition the medicine was being used to treat

When did the patient start taking the medicine?

DayMonthYear

If the patient stopped using the medicine, what was the date it was stopped?

DayMonthYear

If you know of any other Medicines that were used in the past 3 months, please list them. If possible, please include the condition treated

Enter as much information as possible based on availability

When did the reaction start?

DayMonthYear

If the reaction has stopped, please state when the reaction ended

DayMonthYear

If treatment was given, or Action taken, briefly describe here:

Action may include going to the doctor, or taking a medicine to treat the reaction

Seriousness of Adverse Reaction

Please tell us about the Outcome of the Adverse Reaction

Did reaction stop after stopping the medicine or reducing dosage?

Other Relevant Information

Country where product was used or discovered*

Reporter Name*

Your Role

For additional information, we ask that you provide a contact (name & email or phone)

VigiCarib Reporting Form for Suspected Adverse Drug Reactions for Patients/ Caregivers