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Report tuberculin safety event

Our pharmacovigilance program monitors the safety of our drugs. To report an safety event with the PPD TUBERCULIN test, please fill out the form below.

Tuberculin

General Information

Date of Notification

City

Institution where the event took place

Reporter Details

Details of the healthcare professional reporting the event

Name

Last Name

Profession

Phone

Email

Patient Details

Information about the patient that suffered the adverse event

Date of Birth

Age of patient at the time of the AE

ID

Number

Patient Initials

Radio Field

Female

Male

Weight (Kg)

Height (Cm)

Diagnosis

Other Drugs

Register all the drugs prescribed to the patient

Medicine 1

Indication

Dosage

Method of Administration

Posology

Start of Treatment

Medicine 2

Indication

Dosage

Method of Administration

Posology

Start of Treatment

Medicine 3

Indication

Dosage

Method of Administration

Posology

Start of Treatment

Medicine 4

Indication

Dosage

Method of Administration

Posology

Start of Treatment

Medicine 5

Indication

Dosage

Method of Administration

Posology

Start of Treatment

Sales Record

Traceability Details

Entity

City

Medicine

No. Invoice

Date

Quantity

Medication Details

Traceability of the product suspected of causing the adverse event

Medicine

Batch

Expiration Date

Was the medicine vial kept in a dark place?

Yes

No

I do not know

Was the vial of medicine kept at temperatures between 2°C and 8°C?

Yes

No

I do not know

Was the medicine used as a multidose medicine?

Yes

No

I do not know

If the medicine was used as a multidose medicine, was it used up to 4 weeks after opening?

Yes

No

I do not know

Event Details

Description of the adverse event suffered by the patient

Description of the event

Did the event produce or prolong hospitalization?

Yes

No

I do not know

Did the event occur after the administration of the medicine?

Yes

No

I do not know

Did the event cease when the dose of the suspected medicine was reduced or suspended?

Yes

No

I do not know

Did the patient have the same reaction to the suspected medicine previously?

Yes

No

I do not know

Was the medicine administered by a healthcare professional?

Yes

No

I do not know

Was the test read 72 hours after administration?

Yes

No

I do not know

I authorize the processing of my personal data

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