- Indian Pharmacopoeia Commission
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Medical device adverse event report
On this page
I. Patient details
II. Adverse event details
III. Medical device details
IV. Upload relevant document
All fields marked with an asterisk
*
are mandatory
On this page
Mobile Verification
All fields marked with an asterisk
*
are mandatory
Mobile Verification
Mobile no.
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One Time Password
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I. Patient details
Are you a patient?
Yes
No, Somebody else is a patient
Please select whether you are a patient or somebody else is a patient
First name
First name must not exceed 50 characters length
Last name
Last name must not exceed 50 characters length
Initials
?
Please enter initials
Date of birth/ Age
Select
Date of birth
Age
If you know date of birth then please select date of birth or else select age
Date of birth
Please select date of birth
Age
Select
Decade
Year(s)
Month
Week
Day
Hour
Please enter age
Please select age unit
Gender
Select
Female
Male
Transgender
Please select gender
Weight
kg
Address
0/150
Address can not exceed 150 characters in length
Pin code
Please enter a valid pin code
District
Please select district
State
Please select state
Country
Please select country
How do you know the patient?
Select
Family member
Friend
Others
Please select how do you know the patient?
Family member
Others
Please enter relation of family member, must not exceed 50 characters length
Please enter others, must not exceed 50 characters length
II. Adverse event details
Date of event
Please select started date
Location of event
Select
Home
Hospital
Others
Others
Please enter others, must not exceed 60 characters length
IPD/ OPD
Select
IPD
OPD
CR
Please select IPD/ OPD
Please enetr IPD/ OPD no., must not exceed 20 characters length
Hospital name
Please enter hospital name, must not exceed 100 characters length
Hospital address
0/150
Please enter address, must not exceed 150 characters length
Describe the details of adverse event
0/5000
Please describe the details of side effect, must not exceed 5000 characters length
Device operator
Select
Physician
Patient
Others
None or problem prior notice to us
Others
Please enter others, must not exceed 60 characters length
Was device return to local supplier
Select
Yes
No
Date of return
Please select date of return
Specify location
Please enter location, must not exceed 60 characters length
Other relevant information
0/2500
Other relevant information must not exceed 2500 characters length
III. Medical device details
Device name
Please enter device name, must not exceed 100 characters length
Model no.
Please enter model no., must not exceed 50 characters length
Serial no.
Please enter serial no., must not exceed 50 characters length
Batch/ Lot no.
Please enter batch/ lot no., must not exceed 50 characters length
Software version
Please enter software version, must not exceed 50 characters length
Manufacture date
Please select manufacture date
Installation date
Please select installation date
Expiry date
Please select expiry date
Implantation date
Please select implantation date
Device manufacturer name
Please eneter device manufacturer name, must not exceed 60 characters length
Local supplier name
Please eneter local supplier name, must not exceed 60 characters length
IV. Upload relevant document
Document title
Document title can not exceed 60 characters in length. Also, this becomes a required field if document upload field is populated
Upload document
Choose file...
Browse
Upload document file can be of PDF/JPG/MP4 type, and can not exceed 10 MB in size. Also, this becomes a required field if document title field is populated
Submit
Add file
Type: JPG/PDF/MP4 & Max size: 10 MB
Choose file...
Browse
Please choose a valid file
