Reporting Adverse Drug Events - Northwestern Health Unit

Type of event *

Date *

Community *

Details of event *

Please provide only your own contact information for follow-up purposes and avoid including any additional personally identifiable information (PII) about others, such as names, addresses, or medical record numbers. This form is intended solely for reporting adverse drug events, and including unrelated personal details may compromise privacy and data security.

Affiliation of reporting individual *

Affiliation Date of

Name of reporting individual

Contact information for follow-up

Phone number and/or email

Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 800-830-5978 or see the privacy statement on our website at www.nwhu.on.ca.