Adverse Event Reporting for Animals - Office of Research Compliance

Today's date:*
MM slash DD slash YYYY
Name of individual initiating this report:*
Title:*
Email:*
Protocol #:*
Protocol title:*
Reason for submission:*
- Level of mortality experienced are >10% that anticipated in approved protocol.
- Mortality due to unanticipated complications involving the approved protocol.
- Morbidity/non-fatal complications significantly beyond that anticipated in the approved protocol.
Briefly summarize the excessive or unanticipated mortality or morbidity being reported including:
a) Species involved:*
b) Numbers of animals impacted:*
c) Date or date range of incidents:*
d) Describe the adverse event(s) that occurred:*
e) Please list the preliminary cause for the adverse event:*
f) Please list any pending diagnostics or other reports that may explain the cause(s) of the adverse event:*
g) Any additional information, extenuating circumstances or other detail that may be helpful in reviewing this matter.*
Has there been prior communication or consultation with the Attending Veterinarian concerning this event?*
- Yes
- No
If yes, please provide details below.
Details of prior communication or consultation:
Please describe the corrective action plan to reduce or prevent future morbidity or mortality. (If relevant, also add date for when the corrective action is taking place):*

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