Multi-Site Research Adverse Event Tracking Template
Site & Event Details
Site Name
Site Code/ID
Event Date
Event Time
Research Protocol/Study Title
Participant Details
Participant ID
Age
Sex
Female
Male
Other
Event Description
Type of Adverse Event
Event Description
Severity
Mild
Moderate
Severe
Expected Event?
Yes
No
Serious?
Yes
No
Event Outcome
Outcome
Recovered
Ongoing
Recovered with Sequelae
Fatal
Event Resolution Date
Actions Taken
Reporting & Follow-up
Date Reported to Sponsor/IRB
Person Reporting Event
Follow-up/Additional Comments