Adverse Event Reporting Form

Who are you? *

First Name

Last Name

Organization Name

If Other, please describe.

Country *

Postal Code *

Do we have permission to contact you for further information about this case report? * Yes No

If yes, please provide at least one of the following:

Phone Number (including area code)

Email Address

Please provide at least one of the below information regarding the Patient.

Initials

Gender

Age

Age Units

Which Air Products product caused the adverse event(s)/side effect(s)?

Please provide additional details regarding the product, including: Batch / Lot number; Start/stop dates of the product used by the patient; Medical condition or reason for which the product was used; Dosage and administration details (e.g., 5L/min for 15 minutes)

Please describe the adverse event(s)/side effect(s) presented by the patient: *

Please provide additional details regarding the adverse event(s)/side effect(s), including: Date the patient first and last experienced the adverse event(s); If the patient was hospitalized due to the event(s), was in an immediate risk of death or died; If the patient recovered from the event(s)

Please provide any additional details, including: Other diagnosed illnesses / medical history / chronic health conditions; Other treatment drugs used at the time of the event(s); Other relevant information

The personal information you provided about yourself and your patient will be stored in a file registered at the data protection authorities and will be processed by Air Products to meet the pharmacovigilance legal obligations. It will be treated in accordance with the European Regulation 2016/679 and 2018/1725 on Personal Data Protection. The information you provided is for the continuous improvement of knowledge about the use and safety of our pharmaceutical products, and information related to your medical condition will be treated confidentially. Such information may be shared globally with regulatory authorities, other Air Products affiliates, and other parties with pharmacovigilance obligations. You and your patient have the right to access, rectification, cancellation, and opposition anytime you wish by sending your request to pvsystem@airproducts.com.

*Required Field