Now create your own JotForm - It's free!Create your own JotForm
Create your ownJotForm mascot Podo
Question Label
1 of 35See AllGo Back
Welcome! Please fill out and submit this form to report either a (i) Suspected Adverse Medicine (Drug) Reaction, or a (ii) Quality Issue for suspected substandard, unregistered/unlicensed or falsified (SF) medical products to the CARPHA VigiCarib network. For biologics and suspected SF products, the brand or trade name and the manufacturer's name are needed. Patient details are not required for quality issues unless an adverse reaction has occurred. The submission of a report DOES NOT constitute an admission that health personnel caused or contributed to the adverse reaction or quality problem. For further information or assistance, contact us at 
VigiCarib Reporting Form - Confidential v2