Notice of Suspected Adverse Reaction to Veterinary Drugs

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Health Products and Food Branch
Veterinary Drugs Directorate
Notice of Suspected Adverse Reaction to Veterinary Drugs
(including side effects, toxicity, idiosyncrasy, allergy, intolerance, incompatibility, lack of effect)

1. Brand name
   
2. Generic name
   
3. Manufacturer
   
4. Lot No.
   
5. Expiry date - Y/M/D -
   
6. DIN No.
   
7. Date used - Y/M/D -
   
8. Condition of product
   
9. Storage conditions
   
10. Was product used according to label directions ?
    
    Explain
    
    
11. Animal species
    
12. Breed
    
13. Age
    
14. Weight
    
15. Sex
    
    Female  Male  Pregnant  Neutered
    
    
16. Overall state of health at time of reaction
    
    Good  Fair  Poor  Critical
    
    
17. Drug was administered by
    
    Veterinarian  Owner  Other
    
    
18. Number of animals in this incident
    
19. Treated
    
20. Reacted
    
21. Died
    
22. Dosage
    
23. Route
    
    I.V.  I.M.  S.C.  Other (specify)
    
    
24. No. of times treated
    
    
25. Time from last treatment to reaction
    
    
    Min. Hrs. Days
    
    
26. Reaction - Provide description including reason for use of drug,
    management of adverse reaction and outcome. Include results of laboratory testing and necropsy. If the drug was administered via the feed, it would be helpful to provide the name of the feed manufacturer, formulation, bill of sale and feed assay. Please complete on a seperate sheet if necessary.
    
    
27. Concurrent therapy was ant used ? No Yes
    
    If Yes state product, dosage, route, pre or post suspect drug, etc.
    
28. Was this animal/group of animals previously treated with this or similar drug ?
    
    Yes  No
    
    If yes:
    
    
    1. How long prior to this incident ?
       
    2. Brand name of drug used
       
    3. Did this or other animal(s) react adversely ?
       
       No  Yes   Similar  Different
       
       Describe
       
       
29. Owner's name
    
30. Owner's address
    
31. Telephone
    
32. Sender
    
    
33. Street
    
    
34. City
    
    
35. Province
    
    
36. Postal Code
    
37. Telephone
    
38. Signature
    
39. Date
    
40. Veterinarian's name
    
41. Veterinarian's address
    
42. Veterinarian's telephone

Send original to:

Veterinary Drugs Directorate
Health Products and Food Branch
Health Canada
Holland Cross Complex
Tower A, Ground Floor
14-11 Holland Avenue
Address Locator: 3000A
Ottawa, ON K1A 0K9

Adverse Reaction : Tel: (613) 948-2381 Fax: (613) 946-1125

Send copy to manufacturer

Send adverse reactions to Vaccines to:

Canadian Food Inspection Agency
Animal Products Directorate
Animal Health and Production Division
Veterinary Biologics Section
59 Camelot Drive
Ottawa, ON K1A 0Y9