Complaint & Adverse Event Log
A streamlined interface for accurate data entry.
Initial Intake
Complaint ID (Auto-Generated)
Date Received
Form of Contact
Select...
Email
Social Media
Mail
Amazon
Retailer
Initial Intake Completed By
Order Number
Classification
Select...
Adverse Event
Product Complaint
Customer Information
Customer Name
Customer Phone
Customer Email
Product & Event Details
Product Name
Lot Number
Date of Use
Date of Adverse Event
Nature of Complaint
Select...
Headache
Dizziness
Nausea
Vomiting
Digestive Issues
Diarrhea
Allergic Reaction
Rash/Hives
Defective Product
Packaging Issue
Missing Tablet
Taste
Odor
Description of Event
Health & Reporter Information
Product in Possession?
Select...
Yes
No
Medical Attention Sought?
Select...
Yes
No
Hospitalization?
Select...
Yes
No
Healthcare Provider Name
Reporter Relationship
Select...
Self
Spouse
Parent
Health Provider
Other
Serious?
Select...
Yes
No
Internal Actions & Disposition
Corrective Action Taken
Select...
Refunded
Replaced
Trigger for AE Form?
Select...
Yes
No
AE Form Completed By
Date Form Completed
Follow-up Required?
Select...
Yes
No
Follow-up Date
Reported to FDA?
Select...
Yes
No
Date Reported to FDA
Final Disposition
Select...
Open
Pending Investigation
Closed
Reported
Disposition Notes
Closure
Investigator Name
Date Closed
Additional Notes
Submit Record
Submitting...