University Of Mississippi Medwatch Form 3500 printable pdf download

University Of Mississippi Medwatch Form 3500

UNIVERSITY OF MISSISSIPPI SCHOOL OF PHARMACY

INTRODUCTORY PHARMACY PRACTICE EXPERIENCES

Student:

Date:

Rotation Type: INSTITUTIONAL Rotation #:

Preceptor:

Preceptor Signature:

Directions: Complete a MedWatch Form 3500 either online or by hardcopy. If you complete a hardcopy of this form, answer

only the first 2 questions of this document.

The form may be found at the following website:

https://

Instructions for completing the form may be found at:

https://

The MedWatch 3500 form is for reporting serious adverse effects related to what products:

Serious adverse effects of what products should not be reported using the MedWatch 3500 form?

Answer the following questions to assist with completing the online MedWatch 3500 form.

Patient Identifier*:

Patient age:

Patient gender:

Patient Wt:

Adverse event: Date of Event:

Describe the adverse event:

Outcome attributed to adverse event:

Describe relevant tests / laboratory data, including dates:

* Do not use patient’s name of social security number as patient identifier.

INSTITUTIONAL

1 of 2

Adverse Event Reporting

University Of Mississippi Medwatch Form 3500