849 International Drive, 4th Floor, Linthicum, MD, 21090, US
Date of Birth
Sex Assigned at Birth
Affected Individual's Contact Information
Does the affected individual suspect that cannabis caused this adverse event?
Is there a specific 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 GROWER was Contacted
Date PROCESSOR was Contacted
Does the affected individual use any of the following:
Use of Smokable Tobacco:
Use of E-cigarettes or Vaping Devices:
Use of Dabbing Equipment:
Was a healthcare provider visited to assess this adverse event or any of the associated symptoms?
Date of Visit
Were clinical specimens taken?
Was a formal diagnosis made?
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?