VETERINARY ADVERSE DRUG REACTION
Requirement as per FDA Emergency Use Authorization for New World Screw Worm

VETERINARY ADVERSE DRUG REACTION
Requirement as per FDA Emergency Use Authorization for New World Screw Worm

Thank you for taking the time to report a suspected adverse reaction, product quality issue, or lack of effectiveness. Your feedback is essential in helping us monitor product safety, support animal health, and continuously improve treatment outcomes.

Please complete the form below with as much detail as possible. If you have supporting documentation (such as laboratory reports, images, medical records, or treatment notes), you can attach these when replying to the confirmation email you will receive after submitting this form.

If you prefer to complete the form offline, you may download the fillable PDF version using the button below.

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Veterinary Adverse Drug Reaction Report

SENDER INFORMATION

HEALTH CARE PROFESSIONAL INFORMATION

(If different from Sender Information)

OWNER INFORMATION

(if different from Sender information)

PRODUCT USE INFORMATION FOR SUSPECTED PRODUCT

 

ADVERSE EVENT INFORMATION

 

SPECIES AND RELATED INFORMATION

OVERALL HEALTH STATUS WHEN SUSPECTED PRODUCT GIVEN

ADVERSE EVENT OCCURRENCE

DOCUMENT INFORMATION

Please note: File uploads are not available on this form. If you need to include laboratory reports, images, medical records, or supporting documents, please attach all files to the confirmation email after you submit this form.

CONCURRENT CLINICAL PROBLEM(S)

Concurrent Product Information

(Excluding Treatment of Current Event)

ADVERSE EVENT/PRODUCT PROBLEM/EVENT USE ERROR

(Long Narrative)