Partners safety report

Partners safety report

1. External party information

Company name *

Please write the full correct name of your company Please enter company name

Name of partner employee reporting to Novo Nordisk *

Please provide first and last name Please enter your name

E-mail address *

Please provide an e-mail address to which Novo Nordisk can write to get more information about the safety information report Please enter the e-mail address Please enter the valid e-mail address

Revalidate e-mail address *

Please repeat the e-mail address to which Novo Nordisk can write to get more information about the safety information report Please revalidate the e-mail address Please enter the valid e-mail address Please enter the same e-mail address

2. Information about the Safety Information report

Please select your location
Select the location of the person reporting the Safety Information

The location is not in the list? Type here *

If your location is not in the list, please add it here. {{crossValidationError['altCountry'].crossValidationErrorMessage}}

Date of receipt of the Safety Information/Adverse Event report *

This is the calendar day your company received the safety information Please choose date value
Please choose the type of activity/service
Please select the service/activity through which you received the Safety Information
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.

Please specify activity/service *

This field is required

Description of the Adverse Event or other Safety information *

This field is required.

Initial or Follow-up information? *

{{crossValidationError['initialOrFollowUp'].crossValidationErrorMessage}}

ID of report *

Please provide any identification details you have assigned to the report, for example a report ID number, patient ID number etc. You must fill in ID of report

Patient´s age *

{{crossValidationError['age'].crossValidationErrorMessage}}
This field is required

Event start date *

{{crossValidationError['eventStartDate'].crossValidationErrorMessage}}

Event stop date *

{{crossValidationError['eventStopDate'].crossValidationErrorMessage}}
Reported causality assessment is required
Does the patient/reporter think that the Novo Nordisk product might have contributed to the adverse event/safety information?

Attach safety information report/details *

You can attach multiple files by pressing ‘ctrl’ and then clicking on each file which you would like to attach. The total maximum size must not exceed 10 MB. For security reasons only the following file formats are allowed: Word, Excel, PDF, Power Point and Email
Your attachment is too big. You can attach up to 20MB {{crossValidationError['attachment'].crossValidationErrorMessage}}

Patient has been notified of and agrees to

Any personal data related to safety information being reported to Novo Nordisk * * *

Please select an option.

Recording and storing their personal data in Novo Nordisk's overseas global safety database * * *

Please select an option.

Novo Nordisk sharing their personal data with relevant third parties, as required * * *

Please select an option.

Novo Nordisk following up their prescriber about the safety information * * *

Please select an option.

Prescriber name *

{{crossValidationError['prescriberName'].crossValidationErrorMessage}}

Prescriber practice address or phone number *

{{crossValidationError['prescriberContact'].crossValidationErrorMessage}}
This field is required