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.
If you have any questions about this form, you may email us at firstname.lastname@example.org.