SUSAR Report Template
Reporter Information
Name
Contact
Institution
Patient Information
Age
Sex
Male
Female
Other
Patient ID (if available)
Suspected Drug Information
Drug Name
Dose
Route
Treatment Dates
Adverse Reaction Details
Description
Onset Date
Outcome
Seriousness Criteria
Death
Life-threatening
Hospitalization
Disability
Congenital anomaly
Other medically important
Concomitant Medications
List Concomitant Medications
Relevant Medical History
Summary
Additional Information
Other Relevant Details