Enter where it is From (in full with addresses)
Enter where it is to:(see list attached , if more than one)
Enter Product; Brand/Trade Name
Enter INN or Generic Name
Enter Batch Number
Enter Strength
Enter Pack Size and Presentation
Provide expiry date
Provide Date Manufactured
Provide Dosage form
Enter Marketing Authorization Holder and addresses
Enter Manufacturer and Addresses
Enter Details of Defect
provide Product Photo
Enter State Information On Distribution Including Exports (specify type of customer, e.g. hospitals)
Enter Reporter
Enter Reporter Facility
Enter Reporter Telephone
Enter Reporter Cell Phone Number
Enter Reporter Physical Address
Enter Reporter Postal Address
Enter Reporter Signature - Use Full Names
Provide date


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