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Data Entry
for Samoyed Incident Report
(Companion
Database)
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Samoyed Identification
Code*:
*Required
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To
use this form, your Samoyed must already be entered in the SCARF main
database. You must
use that same "identification code"
number here. This code links together all of the databases of
information for this particular dog. If you do not have this
Samoyed entered into the main database, click here
to add your Samoyed's record. Then return here to complete this
report using the same "identification
number" you used to enter the record into the main
database. |
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Category of
Participant*:
*Required
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| Product information |
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Suspected Product:
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Product Form:
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pill, liquid,
inhalant, salve/ointment, kibble etc. |
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Manufacturer's Name:
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Amount Administered:
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mg, ml, tbs, cup, etc |
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Route of Administration:
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oral, intramuscular,
intravenous, subcutaneous, inhaled (like anesthetic, etc.) |
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Length of use:
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number of hours, days, weeks etc. |
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Who Administered Product?:
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owner, veterinarian, vet. tech., etc. |
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Other products:
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List any other products that were used by this Samoyed at
the time or onset of this incident. |
| Reaction Information |
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Date of Event:
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(mm/dd/yyyy)
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Event Details:
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Please describe the reaction
adding details about case history and outcome if possible. Comment on
any contributing factors or suspected product defects. List any
concurrent clinical problems. If known, include time of day, symptoms,
length of occurrence, medications given and results.
Example - My Samoyed was given Rimadyl because of arthritis in the
hips. My dog was lethargic, had loss of appetite, and vomited
excessively every time they received a 100 mg Rimadyl caplet. Upon stopping the
medication, my dog returned to normal.........etc.) |
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Time between initiation of product and
onset of reaction:
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Time between last administration and onset
of reaction:
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minutes, hours, days
etc. |
| Outcome: |
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Recovered
from reaction |
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Died |
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Other (Comment below) |
| Was the reaction treated?: |
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Yes |
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No |
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If yes, please comment:
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| When reaction occurred usage of the product: |
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Had been completed |
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Was discontinued due to reaction |
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Was discontinued and replaced with
another product (comment below) |
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Was continued with a different dose
(comment below) |
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Other( comment below) |
| And the reaction: |
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Continued |
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Stopped |
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Recurred
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Other (comment below) |
| Level of Suspicion: |
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High: |
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Medium: |
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Low: |
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Other Comments to Reaction Information:
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