Individual Case Safety Report (ICSR) Form
Patient Name:
Patient Age:
Patient Gender:
Select Gender
Male
Female
Other
Drug Name:
Drug Dosage:
Reaction Description:
Reaction Start Date:
Reaction End Date (if applicable):
Reaction Outcome:
Select Outcome
Recovered
Recovering
Not Recovered
Fatal
Reporter Name:
Reporter Email:
Reporter Phone:
Submit ICSR