Form DCF-465B "Suspected Adverse Drug Reaction Reporting Form" - Connecticut

What Is Form DCF-465B?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-465B by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-465B "Suspected Adverse Drug Reaction Reporting Form" - Connecticut

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Connecticut Department of Children and Families
SUSPECTED ADVERSE DRUG REACTION REPORTING FORM (FAX TO: 1-877-DCF-DRUG)
DCF-465B
12/12 (Rev.)
Page 1 of 1
IF ADVERSE DRUG REACTION (ADR) TO A MEDICATION IS SUSPECTED, NOTIFY THE PRESCRIBING AND/OR ATTENDING PHYSICIAN
IMMEDIATELY. COMPLETE SECTION BELOW AND FAX TO DCF CENTRALIZED MEDICATION CONSENT UNIT AT 1-877-DCF-DRUG OR
E-MAIL TO
GETMEDS@CT.GOV
SECTION I: To be completed by the individual discovering the suspected ADR
Client Name:
Date:
Location:
LINK#
Suspected Medication:
Dosage Regimen:
Date of 1
Time of
Date of
Time of
st
Dose
1
Dose
Reaction
Reaction
st
MD
RN
APRN
RPH
Reported by:
Other:
Responsible Physician
Physician Notified?:
Yes
No
TYPE OF REACTION (check all that apply)
Rash
Diarrhea
Nausea
Fever
Hypotension
Vomiting
GI Upset
Abnormal lab
Describe:
Blood dyscrasia (type):
EPS (type)
Vertigo
Tachycardia
Hypersalivation
Other:
SECTION II: To be completed by DCF Clinical Pharmacist. For significant ADR’s check all that apply
ADR was reason for hospital admission
Medication was required to treat the ADR (Please list Medication:
ADR resulted in temporary / permanent disability (Please Describe:
ADR prolonged hospital stay
Other treatments were needed to resolve the ADR (Please Describe:
ADR was reported to the FDA
ADR was:
Idiosyncratic
Dose related (Please Explain):
Know drug allergies:
Other current medication:
DCF Clinical Pharmacist:
Date:
SECTION III: TDCF Psychotropic Medication Advisory Committee Review of Possible ADR
Yes
No
Agree the ADR was significant and probable / highly probable
Yes
No
Was there an indication for the use of the suspected drug?
Yes
No
Was the dose within the recommended range?
Yes
No
Were there any contraindications present?
Comments / recommendations:
Reviewed by:
Date:
Connecticut Department of Children and Families
SUSPECTED ADVERSE DRUG REACTION REPORTING FORM (FAX TO: 1-877-DCF-DRUG)
DCF-465B
12/12 (Rev.)
Page 1 of 1
IF ADVERSE DRUG REACTION (ADR) TO A MEDICATION IS SUSPECTED, NOTIFY THE PRESCRIBING AND/OR ATTENDING PHYSICIAN
IMMEDIATELY. COMPLETE SECTION BELOW AND FAX TO DCF CENTRALIZED MEDICATION CONSENT UNIT AT 1-877-DCF-DRUG OR
E-MAIL TO
GETMEDS@CT.GOV
SECTION I: To be completed by the individual discovering the suspected ADR
Client Name:
Date:
Location:
LINK#
Suspected Medication:
Dosage Regimen:
Date of 1
Time of
Date of
Time of
st
Dose
1
Dose
Reaction
Reaction
st
MD
RN
APRN
RPH
Reported by:
Other:
Responsible Physician
Physician Notified?:
Yes
No
TYPE OF REACTION (check all that apply)
Rash
Diarrhea
Nausea
Fever
Hypotension
Vomiting
GI Upset
Abnormal lab
Describe:
Blood dyscrasia (type):
EPS (type)
Vertigo
Tachycardia
Hypersalivation
Other:
SECTION II: To be completed by DCF Clinical Pharmacist. For significant ADR’s check all that apply
ADR was reason for hospital admission
Medication was required to treat the ADR (Please list Medication:
ADR resulted in temporary / permanent disability (Please Describe:
ADR prolonged hospital stay
Other treatments were needed to resolve the ADR (Please Describe:
ADR was reported to the FDA
ADR was:
Idiosyncratic
Dose related (Please Explain):
Know drug allergies:
Other current medication:
DCF Clinical Pharmacist:
Date:
SECTION III: TDCF Psychotropic Medication Advisory Committee Review of Possible ADR
Yes
No
Agree the ADR was significant and probable / highly probable
Yes
No
Was there an indication for the use of the suspected drug?
Yes
No
Was the dose within the recommended range?
Yes
No
Were there any contraindications present?
Comments / recommendations:
Reviewed by:
Date: