ASRS Adverse Event Report Form

Enter as much information as you can about the adverse event(s) for the product or device.

Someone from the Research and Safety in Therapeutics (ReST) Committee will contact you as soon as possible.


Reporter Information

(xxx) xxx-xxxx

Product Being Reported

mm/dd/yyyy

Device Being Reported

mm/dd/yyyy

Adverse Event, Product Problem, or Error

mm/dd/yyyy
mm/dd/yyyy
Enter dates in mm/dd/yyyy
Preexisting conditions, allergies, race, pregnancy, smokling, alcohol use, liver/kidney problems
Specific date(s) or estimated date range
Cancel
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