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The Irish Medicines Board -

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Serious Adverse Event Form Investigator Lead Clinical Trials
Form Information
Fields marked with an asterisk (*) are mandatory. To move through the steps of the form please use the Next and Previous buttons that are at the bottom of the form.
General Information
Irish Medicines Board Clinical Trial Number:
Study Protocol Number:
Irish Medicines Board Reference No. (for follow up reports only):
Steps :
Step 1  General Information
Step 2  Reporter Information
Step 3  Investigator Information
Step 4  Patient Information
Step 5  Adverse Event Details
Step 6  Suspect Drug Information

Date Printed: 16 April 2014

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