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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

Name

Address

Phone*: (xxx) xxx-xxxx

Email*

Product Being Reported

Product name

Product manufacturer

City/State

Dose

Lot #

Expiration date: mm/dd/yyyy

Event abated after use stopped or dose reduced?

Yes
No
N/A

Did you return the product to the manufacturer?

Yes
No

Any additional information about this product?

Device Being Reported

Product name

Product manufacturer

City/State

Model #

Lot #

Expiration date: mm/dd/yyyy

For injections, did you use the syringe that was supplied with the drug?

Yes
No
N/A

Any additional information about this device?

Adverse Event, Product Problem, or Error

Number of patients infected

Describe the adverse event

Date of event: mm/dd/yyyy

Today's date: mm/dd/yyyy

Relevant tests/Laboratory data, including dates: Enter dates in mm/dd/yyyy

Other relevant history(s) for patient(s): Preexisting conditions, allergies, race, pregnancy, smokling, alcohol use, liver/kidney problems

Date(s) of use: Specific date(s) or estimated date range

Diagnosis/Reason for use


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