Gender:

Male
Female

Postcode:

If not in Australia, what country?

Age:

 years

 months ( if baby )

Report submitted by?

Consumer (self)
Relative
Doctor
Other

If other, please specify:

What type of medicine incident do you want to report?

Error causing injury
Close call
Error not causing injury
Quality issue

Do you think the incident was preventable?

Yes
No

If yes, why do you think the incident was preventable?

About the medicine(s) you suspect caused the incident:
(Details can be found on the label or packaging)

Medicine 1

Name of Medicine
Dosage
How did you take the medicine	By mouth Ear Eye Inhalation Injection Nose Patch Skin application Suppository Under tongue Vaginal Other
Reason for use
When did you start taking the medication?	-- date or approx time
When did you stop taking the medication?	-- date or approx time
If stopped, by whom?	(eg self, doctor, pharmacist)

Medicine 2

Name of Medicine
Dosage
How did you take the medicine	By mouth Ear Eye Inhalation Injection Nose Patch Skin application Suppository Under tongue Vaginal Other
Reason for use
When did you start taking the medication?	-- date or approx time
When did you stop taking the medication?	-- date or approx time
If stopped, by whom?	(eg self, doctor, pharmacist)

Medicine 3

Name of Medicine
Dosage
How did you take the medicine	By mouth Ear Eye Inhalation Injection Nose Patch Skin application Suppository Under tongue Vaginal Other
Reason for use
When did you start taking the medication?	-- date or approx time
When did you stop taking the medication?	-- date or approx time
If stopped, by whom?	(eg self, doctor, pharmacist)

List other medicines (or herbal remedies) by brand name taken within 3 months of the incident?
Details can be found on the label or packaging.

Date of incident or symptoms:

-- dd/mm/yy or approximate date

Description of the incident or symptoms

Do you think that any of the following factors contributed to the medicine incident?
(check all that apply)

If other, please specify.

Outcomes attributed to the medicine incident
(check all that apply)

Did this medicine incident result in any medicine changes?
(check all that apply)

Dose changed    Drug continued  Drug ceased     Drug Replaced 

Your own story

Optional Information:

Contact information:

Name
Telephone(incl STD code)
E-mail