Consumer Form for filing Adverse Event
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1
Consumer Details
2
Event Information
3
Product Information
4
Review and Confirm
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Notification Email (Owner)
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Fetched Email Addresses
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Company Name
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User ID
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CD Record Number
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Dropdown
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Product name text
Consumer Information
Please enter the contact information for the person who experienced the adverse event.
Consumer Name
*
Consumer Email
*
Consumer Phone
*
Consumer Address 1
Consumer Address 2
Consumer City
*
Consumer State
*
Consumer Postal Code
Consumer Date of Birth
*
Please enter the date in MM/DD/YYYY format.
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Consumer Date of Birth
*
Please enter the date in MM/DD/YYYY format.
MM slash DD slash YYYY
Sex
Please Select
Male
Female
Non-binary and/or Intersex
Decline to answer
Gender
Please Select
Cisgender man/boy (gender corresponds with birth sex)
Cisgender woman/girl (gender corresponds with birth sex)
Transgender man/trans man/ female-to-man (FTM)
Transgender woman/trans woman/male-to-female (MTF)
Decline to answer
Other gender category
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Please specify gender
*
If other please specify
*
Include as many details as possible
Weight
Weight Unit
Lbs
Kg
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Person reporting this information is different than the consumer above
Person reporting this information is different than the consumer above.
Reporter Information
Please enter the contact information the person reporting the adverse event.
Same as Consumer
Use consumer address information.
Are you a health professional?
Yes
No
Also sent the report to FDA?
Yes
No
Unknown
Reporter First Name
*
Reporter Last Name
*
Reporter Email
*
Reporter Phone
*
Reporter Occupation
Please Select
Administrator/Supervisor
Biomedical Engineer
Dentist
Non-Health Professional
Nurse
Nurse Practitioner
Other Health Professional
Pharmacist
Physician
Physician Assistant
Risk Manager
Third Party Servicer
Reporter Address 1
Reporter Address 2
Reporter City
*
Reporter State
*
Reporter Postal Code
Adverse Event Information
About the Problem
(Check all that apply)
Had a bad side effect (
including new or worsening symptoms
)
Used a product incorrectly which could have led to a problem
Noticed a problem with the quality of the product
Did any of the following occur?
*
(Check all that apply)
Life-threatening experience
Hospitalization (initial or prolonged)
Required intervention to Prevent Permanent Impairment/Damage
Significant disfigurement
Serious and persistent rashes
Second or third degree burns
Significant hair loss
Persistent or significant alteration of appearance
Congenital anomaly/Birth Defects
Infection
Death
Other
Date of Demise?
*
Please enter the date in MM/DD/YYYY format.
Other
*
When did this event occur?
*
Please enter the date in MM/DD/YYYY format.
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When did this event occur?
*
MM slash DD slash YYYY
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Product Information
*
Product Name
Describe the event and how it happened
*
Include as many details as possible
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Are you allergic to any medications, food or other products
Are you allergic to any medications, food or other products
Other diagnosed illnesses / medical history / chronic health conditions
Relevant Test/Laboratory Data
Upload Test or Lab Reports
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 256 MB.
Product Information
Product Name
*
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Brand Name
*
Product Name
*
Please Select
CREMA VISO GIORNO IDRATANTE 15 - 50 ML
SAPONE VIA CAMERELLE 125 GR
SAPONE DA BARBA UOMO 150 GR
SAPONE CARTHUSIA UOMO 30 GR 30GR
SAPONE GELSOMINI DI CAPRI 125 GR
DETERGENTE VISO EFFETTO VELLUTO 25 - 100 ML
CREMA VISO NOTTE ANTIAGE 50 ML
SIERO VISO ILLUMINANTE 15 - 30 ML
SAPONE MEDITERRANEO 125 GR
SAPONE LIQUIDO VIA CAMERELLE 350 ML
SAPONE LIQUIDO FIORI DI CAPRI 350 ML
SAPONE CORALLIUM 125 GR
CONTORNO OCCHI IDRATANTE 15 ML
SAPONE CARTHUSIA UOMO 125 GR
SAPONE LIQUIDO GELSOMINI 350 ML
SAPONE LIQUIDO CORALLIUM 350 ML
IGIENIZZANTE MANI MEDITERRANEO 100ML
BODY WASH MEDITERRANEO - 250ML
CREMA MANI GELSOMINI - 25ML
BODY WASH CORALLIUM - 50ML
SAPONE 30 GR FIORI DI CAPRI
EAU DE PARFUM 25 ML - CARTHUSIA UOMO
CREMA MANI MEDITERRANEO - 75ML
SHOWER GEL FIORI DI CAPRI - 250ML
EAU DE PARFUM 100 ML - FIORI DI CAPRI
CREMA MANI CORALLIUM - 25ML
BODY LOTION VIA CAMERELLE - 50ML
EAU DE PARFUM 100 ML - 1681
EAU DE PARFUM 100ML - A MMARE
CREMA MANI CORALLIUM - 75ML
IGIENIZZANTE MANI MEDITERRANEO 500ML
EAU DE PARFUM 100 ML - CARTHUSIA UOMO
DEO STICK 075 CARTHUSIA UOMO
BATH FOAM A MMARE
BODY LOTION CARTHUSIA UOMO - 250ML
OLIO DOCCIA A MMARE
FLUIDO RASATURA CARTHUSIA UOMO 25 ML
EAU DE PARFUM 100 ML - GELSOMINI DI CAPRI
SAPONE 30 GR MEDITERRANEO
MOUSSE DOCCIA A MMARE
EAU DE PARFUM 100 ML - MEDITERRANEO
EAU DE PARFUM 50 ML - MEDITERRANEO
TALCO PROFUMATO FORGET ME NOT 100 GR
SHOWER GEL CORALLIUM - 50ML
BODY LOTION FIORI DI CAPRI - 250ML
BODY WASH FIORI DI CAPRI - 50ML
EAU DE PARFUM 100 ML - IO CAPRI
BODY CREAM A MMARE
EAU DE PARFUM 100 ML - VIA CAMERELLE
CREMA MANI MEDITERRANEO - 25ML
CREMA MANI FIORI DI CAPRI - 25ML
EAU DE PARFUM 50 ML - LIGEA LA SIRENA
BODY WASH CAPRI FORGET ME NOT - 200ML
EAU DE PARFUM 50 ML - CARTHUSIA LADY
SAPONE 30 GR VIA CAMERELLE
EAU DE PARFUM 50 ML - FIORI DI CAPRI
BODY WASH CARTHUSIA UOMO - 50ML
EAU DE PARFUM 100 ML - LIGEA LA SIRENA
DOPO BARBA CARTHUSIA UOMO 100 ML
EAU DE PARFUM 100 ML - ARIA DI CAPRI
BODY WASH CORALLIUM - 250ML
CREMA DOPOSOLE A MMARE
SAPONE 30 GR CORALLIUM
EAU DE PARFUM 25 ML - ESSENCE OF THE PARK
CREMA MANI FIORI DI CAPRI - 75ML
SHOWER GEL CARTHUSIA UOMO - 250ML
BODY WASH GELSOMINI - 250ML
SHOWER GEL CAPRI FORGET ME NOT - 200ML
BODY LOTION CORALLIUM - 250ML
EAU DE PARFUM 100 ML - NUMERO UNO
BODY WASH GELSOMINI - 50ML
EAU DE PARFUM 100 ML - CARTHUSIA LADY
SAPONE FIORI DI CAPRI 125 GR
SAPONE LIQUIDO MEDITERRANEO 350 ML
FLUIDO RASATURA CARTHUSIA UOMO 100 ML
BODY LOTION FIORI DI CAPRI - 50ML
EAU DE PARFUM 100ML - TERRA MIA
EAU DE PARFUM 25 ML - FIORI DI CAPRI
SALVIETTINA FIORI DI CAPRI
CREMA MANI GELSOMINI - 75ML
EAU DE PARFUM 50 ML - VIA CAMERELLE
EAU DE PARFUM 50 ML - GELSOMINI DI CAPRI
EAU DE PARFUM 100 ML - TUBEROSA
SHOWER GEL CARTHUSIA UOMO - 50ML
EAU DE PARFUM 100 ML - FORGET ME NOT
PROFUMO SOLIDO FIORI DI CAPRI
BODY LOTION CARTHUSIA UOMO - 50ML
SAPONE 30 GR GELSOMINI DI CAPRI
EAU DE PARFUM 50 ML - IO CAPRI
PROFUMO SOLIDO MEDITERRANEO
EAU DE PARFUM 25 ML - CORALLIUM
EAU DE PARFUM 50ML - TERRA MIA
ROLL-ON A MMARE
EAU DE PARFUM 100 ML - ESSENCE OF THE PARK
SHOWER GEL CORALLIUM - 250ML
PROFUMO PRIMA SAN CARLO EAU DE PARFUM PRIMA SAN CARLO
PROFUMO SOLIDO AMMARE
EAU DE PARFUM 50 ML - CORALLIUM
SHOWER GEL GELSOMINI - 250ML
SHOWER GEL MEDITERRANEO - 250ML
EAU DE PARFUM 50 ML - FORGET ME NOT
BODY WASH FIORI DI CAPRI - 250ML
SHOWER GEL VIA CAMERELLE - 250ML
BODY WASH MEDITERRANEO - 50ML
BODY LOTION GELSOMINI - 50ML
CREMA MANI VIA CAMERELLE - 75ML
EAU DE PARFUM 50 ML - A MMARE
BODY LOTION MEDITERRANEO - 50ML
EAU DE PARFUM 50 ML - NUMERO UNO
EAU DE PARFUM 100 ML - CORALLIUM
CREMA MANI VIA CAMERELLE - 25ML
BODY LOTION MEDITERRANEO - 250ML
SHOWER GEL VIA CAMERELLE - 50ML
BODY WASH VIA CAMERELLE - 250ML
BODY WASH CARTHUSIA UOMO - 250ML
EAU DE PARFUM 25 ML - VIA CAMERELLE
SHOWER GEL MEDITERRANEO - 50ML
SHOWER GEL FIORI DI CAPRI - 50ML
OLIO DA BARBA CARTHUSIA UOMO
PROFUMO PRIMA SAN CARLO 50ML
SHOWER GEL GELSOMINI - 50ML
BODY LOTION VIA CAMERELLE - 250ML
DOPO BARBA CARTHUSIA UOMO 25 ML
EAU DE PARFUM 50 ML - TUBEROSA
BODY LOTION GELSOMINI - 250ML
EAU DE PARFUM 50 ML - ESSENCE OF THE PARK
BODY LOTION CORALLIUM - 50ML
BODY WASH VIA CAMERELLE - 50ML
EAU DE PARFUM 50 ML - ARIA DI CAPRI
EAU DE PARFUM 50 ML - CARTHUSIA UOMO
EAU DE PARFUM 25 ML - MEDITERRANEO
EAU DE PARFUM 50 ML - 1681
BODY WASH TERRA MIA 50 ML - 250 ML
BODY FLUID TERRA MIA 50 ML - 250 ML
CREMA MANI TERRA MIA 25 ML - 75 ML
LIQUID SOAP TERRA MIA 350 ML
Brand Name
*
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Manufacturer
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Packer
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Distributor
Date of first use?
Please enter the date in MM/DD/YYYY format.
Date of last use?
Please enter the date in MM/DD/YYYY format.
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Date of first use?
MM slash DD slash YYYY
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Date of last use?
MM slash DD slash YYYY
Do you still have the product?
*
Yes
No
Do you have a picture of the product?
Yes
No
Front and Back of Label
*
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, doc, Max. file size: 256 MB.
Is this product labeled for single use?
Yes
No
Expiration Date
Please enter the date in MM/YYYY format.
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Expiration Date
MM slash DD slash YYYY
Product Identifier
Product Batch No.
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Serial Number
Event reappeared after reintroduction?
Yes
No
Does not apply
Retailer Information
Retailer Name
Retailer Address 1
Retailer Address 2
Retailer City
Retailer State
Retailer Postal Code
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Retailer Website
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Retailer Phone
Review And Confirm
Consumer Information
Reporter Information
Event Information
Product Information
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