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Questions? Contact Aurash Soroosh, Cannabis-Infused Product Safety Analyst:

aurashj.soroosh@maryland.gov

849 International Drive, 4th Floor, Linthicum, MD, 21090, US

Serious Adverse Event Reporting Form

Medical cannabis patients, caregivers, healthcare professionals, and licensees (Dispensaries, Growers, Processors) are encouraged to submit this form to report an occurrence of a serious adverse event related to the use of medical cannabis.

REPORT INFORMATION

PERSONAL INFORMATION OF THE AFFECTED INDIVIDUAL

Full Name

Date of Birth

Sex Assigned at Birth

Affected Individual's Contact Information

SUSPECTED ITEM INFORMATION

Does the affected individual suspect that cannabis caused this adverse event?

Is there a specific medical cannabis product that is suspected to have caused this adverse event?

Does the affected individual still have this item, its packaging, or the receipt of purchase? If so, please retain the item, packaging, or receipt of purchase for investigation purposes.

Please upload a photo of the product and/or packaging, and/or any other relevant files.

Has the Dispensary/Grower/Processor been contacted about this issue?

Date DISPENSARY was Contacted

Date Picker

Date GROWER was Contacted

Date Picker

Date PROCESSOR was Contacted

Date Picker

MEDICAL HISTORY

Does the affected individual use any of the following:

Use of Smokable Tobacco:

Use of E-cigarettes or Vaping Devices:

Use of Dabbing Equipment:

Please check all symptoms related to this adverse event:

CLINICAL INFORMATION

Was a healthcare provider visited to assess this adverse event or any of the associated symptoms?

Date of Visit

Date Picker

Were clinical specimens taken?

Was a formal diagnosis made?

OTHER EXPOSURES

Please check all that apply:


Has anyone else who the affected individual has been in contact with experienced similar symptoms?

Does the affected individual care for an ill individual at home or do they visit healthcare centers frequently?

May we contact whoever submitted this report for more information?

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