druginfo@drugservice.gov.bb
Level 6 & 7, Warrens Towers II, Warrens, St. Michael
(246) 535-4300 / (246) 535-4322
BARBADOS DRUG SERVICEADVERSE DRUG REACTION REPORTING FORM
SECTION 1: PATIENT INFORMATION
NOTE: Patient details would be kept confidential
Date of Birth
Gender
Patient's Known Allergies
Date of Onset of Reaction
Date Reported
Date Patient Started Using Medication (YYYY/MM/DD)
Date Patient Stopped Using Medication (YYYY/MM/DD)
SECTION 2: SUSPECTED MEDICATIONS/VACCINES INFORMATION: FOR VACCINES OR BIOLOGICS; INDICATE BATCH NO.
Other Drugs Used Concomitantly
Management of Adverse Drug Reaction
Treatment Given
Outcome
If fatal, Date of Death: (YYYY/MM/DD)
If De-challenge was conducted
If Re-challenge was conducted
Causality (Optional) WHO Probability Scale
SECTION 3: REPORTER DETAILS
NOTE: Reporter details would be kept confidential
Name & Profession of Reporter
