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Delay Time

20 Minutes

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Report a side effect \ adverse event - Teva employee form

When was the adverse event reported to Teva employee?

Reference Number

Add all available report numbers or case identifiers. If this is a Follow-up add initial report number.

Would you like to add another reference number?

Yes

Reference Number

Patient Information

(Please provide a response to at least 1 of the fields in Blue)

Patient's Initials:

Date of Birth

Age (Years)

Age Group

Gender

What is patient's gender

Other/ Prefer not to disclose

Contact Information

Country Required

Does Teva have permission to contact the employee about this report?

Yes

Phone

Does Teva have permission to contact the patient about this report?

Yes

Phone

E-mail

Does Teva have permission to contact patient's healthcare provider about this report?

Yes

First Name

Last Name

Qualification

Phone

Does Teva have permission to contact the reporter?

Yes

Reporter

(Teva employee is not considered the reporter. Please add details of the person who reported the adverse event)

Reporters' Last Name or Initials

Reporter's First Name or Initials

Reporter's Phone

Reporter's E-mail

Reporter's Street Address

Reporter's City

Reporter's State/Province/County

Reporters' Postal Code

Product

What is the product you want to report about? Please include details such as dose, dosage form, frequency, route of administration required

Product Start Date

Product Stop Date

Indication

Batch/Lot number

Was the patient taking other medication at the time of the event?

Yes

What is the product you want to report about? Please include details such as dose, dosage form, frequency, route of administration

Product Start Date

Product Stop Date

Indication

Batch/Lot number

Adverse Event

Please briefly list the adverse events or side effects here. Please add full description in the narrative.

When did the adverse event start?

When did the adverse event end?

Did the patient recover from the adverse event?

Narrative

Please describe the adverse events or include additional relevant information regarding the report

Medical History

Does the patient have other diagnosed illnesses / medical history / chronic health conditions? Please add details and dates. Please indicate if patient is a tobacco smoker or alcohol consumer.

Yes

Other diagnosed illnesses / medical history / chronic health conditions

Start date of the condition

Is the condition continuing?

End date of the condition

Attach a file here

Please upload a photo of the product box/package if available, or any other related document for this report

Consent to the processing of your personal data is required Required

I confirm that the details I have provided are correct

By clicking the "Submit" button, you confirm your consent to the processing of the personal data as provided in the report. Personal data will be used by Teva Pharmaceutical Industries Ltd. and its affiliates solely to meet our obligations, and may be transferred out of your country.

For more information on how Teva processes your personal data, including information on your data protection rights, please visit our privacy policy.

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