Pharmaceutical Products Quality Reporting Form

Product type

Drug

Vaccine

Herbal

Other

Product Name (Generic & Brand):

*

Manufacturer

*

Dosage Form

Strength

Package size:

Batch no.

Distributor / Vendor:

Manufacturing date:

Expiry date:

Has the manufacturer been informed?

No

Yes

Date of informed

Packaging

Physical, chemical or microbial changes

Suspected counterfeit product

Product confusion (caused by name, labeling, design or packaging)

Questionable stability

Suspected contamination

Defective components

Labeling Problems (caused by printing errors / omissions)

Other : ...

If Therapeutic failure (please provide patient’s details)

Patient’s Name/or Initial:

Sex:

Female

Male

Weight(Kg):

*

Height:(Cm):

*

Patient’s Medical Record:

Health Institution:

Age

*