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Safety report form

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Safety report form

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 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. test

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

This is the first calendar day your company had access to/became aware of 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

Programme unique identifier *

Number that has been provided by Novo Nordisk. Must be added for MRP This field is required

Programme unique identifier *

Number that has been provided by Novo Nordisk. Must be added for PSP This field is required

Please specify activity/service *

This field is required

Comment *

Optional field where you can add comments to the safety information report. If the available safety information is limited you can choose to write it directly in this field. Clearly mark what is Safety Information and what are your own personal comments {{crossValidationError['comment'].crossValidationErrorMessage}}

Initial or Follow-up information? *

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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

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
You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml, {{crossValidationError['attachment'].crossValidationErrorMessage}}

3. Consent and data privacy

Notice of personal data processing * *

You must accept Privacy Disclaimer
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Your name *

Please enter your name

Your e-mail *

Must be a valid email address Value must a valid email

Your message *

Please add a message

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Your attachment is too big. You can attach up to 20MB Following file extensions are allowed .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpeg,.png {{crossValidationError['attachment'].crossValidationErrorMessage}}
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Your name *

Please enter your name

Your e-mail *

Must be a valid email address Value must a valid email

Your message *

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Your attachment is too big. You can attach up to 20MB Following file extensions are allowed .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpeg,.png {{crossValidationError['attachment'].crossValidationErrorMessage}}
You may for example attach images, reports or other files which may aid in the understanding and handling of your complaint. When you attach, please be patient on submission of your message.

Privacy disclaimer * *

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Your name *

Please enter your name

Your e-mail *

Must be a valid email address Value must a valid email

Your message *

Please add a message

*

Your attachment is too big. You can attach up to 20MB Following file extensions are allowed .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpeg,.png {{crossValidationError['attachment'].crossValidationErrorMessage}}
You may for example attach images, reports or other files which may aid in the understanding and handling of your complaint. When you attach, please be patient on submission of your message.

Privacy disclaimer * *

You must accept Privacy Disclaimer
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Contact us

Your name *

Please enter your name

Your e-mail *

Must be a valid email address Value must a valid email

Your message *

Please add a message

*

Your attachment is too big. You can attach up to 20MB Following file extensions are allowed .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpeg,.png {{crossValidationError['attachment'].crossValidationErrorMessage}}
You may for example attach images, reports or other files which may aid in the understanding and handling of your complaint. When you attach, please be patient on submission of your message.

Privacy disclaimer * *

You must accept Privacy Disclaimer
Recaptcha required

Contact us

Contact us

Your name *

Please enter your name

Your e-mail *

Must be a valid email address Value must a valid email

Your message *

Please add a message

*

Your attachment is too big. You can attach up to 20MB Following file extensions are allowed .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpeg,.png {{crossValidationError['attachment'].crossValidationErrorMessage}}
You may for example attach images, reports or other files which may aid in the understanding and handling of your complaint. When you attach, please be patient on submission of your message.

Privacy disclaimer * *

You must accept Privacy Disclaimer
reCAPTCHA verification required