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Adverse Form

ADR REPORTING FORM

ADVERSE EVENT FORM

Information about the patient who experienced the event:

Details of the reaction(including relevant Tests/Lab Data):

What happened to the patient:

Patient Died

Yes No

Patient Hospitalized

Yes No

Life-Threatening

Yes No

Significant Disability or Incapacity

Yes No

Which OBS AGP drug was involved:

Concomitant Drugs & Date of Administration (Exclude those used to treat reactions):

Who reported the adverse event?

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