Serious Adverse Event Reporting Form

Medical cannabis patients, caregivers, adult-users, 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 cannabis.

REPORT INFORMATION

Date of Report *

Date of Adverse Event *

Relation to the Affected Individual

PERSONAL INFORMATION OF THE AFFECTED INDIVIDUAL

Sex Assigned at Birth

Male

Female

Intersex

MCA Patient ID # (if applicable)

Affected Individual's Contact Information

Telephone

Occupation

SUSPECTED ITEM INFORMATION

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

Yes

Maybe

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

Yes

Please provide any applicable details about the cannabis.

Please provide the product name, including the brand, and a description of the suspected item.

Lot # and Expiration Date of Suspected Item

List anything noted as unusual about the cannabis product.

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.

Yes

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

Click Here to Upload

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

Yes

Dispensary

Grower

Processor

Name of Dispensary (please provide Licensee number if available)

Date DISPENSARY was Contacted

Name of Agent Spoken to

Name of Grower (please provide Licensee number if available)

Date GROWER was Contacted

Name of Agent Spoken to

Name of Processor (please provide Licensee number if available)

Date PROCESSOR was Contacted

Name of Agent Spoken to

MEDICAL HISTORY

Please list all past or existing medical conditions.

Please list all prescription medications or other drugs taken near the time of the incident.

Does the affected individual use any of the following:

Smokable Tobacco

Electronic Cigarettes / Vaping Devices

Dabbing Equipment

Unknown

Use of Smokable Tobacco:

Currently

Previously

Please describe the frequency of tobacco use.

Use of E-cigarettes or Vaping Devices:

Currently (non-cannabis)

Currently (cannabis)

Previously (non-cannabis)

Previously (cannabis)

Please describe the CURRENT frequency of use (non-cannabis).

Please describe the CURRENT frequency of use (cannabis).

Please describe the PREVIOUS frequency of use (non-cannabis).

Please describe the PREVIOUS frequency of use (cannabis).

Use of Dabbing Equipment:

Currently

Previously

Please describe the frequency of dabbing equipment use.

Please check all symptoms related to this adverse event:

Please provide date of onset and cessation of DIARRHEA, as well as any additional important details (including the consistency).

Please provide date of onset and cessation of BLOOD IN STOOL, as well as any additional important details.

Please provide date of onset and cessation of BLOOD IN SPUTUM, as well as any additional important details.

Please provide date of onset and cessation of FEVER, as well as any additional important details.

Please provide date of onset and cessation of FAINTING, as well as any additional important details.

Please provide date of onset and cessation of CHANGES IN HEART RATE, as well as any additional important details.

Please provide date of onset and cessation of NAUSEA, as well as any additional important details.

Please provide date of onset and cessation of VOMITING, as well as any additional important details.

Please provide date of onset and cessation of CONSTIPATION, as well as any additional important details.

Please provide date of onset and cessation of JAUNDICE, as well as any additional important details.

Please provide date of onset and cessation of ANAPHYLAXIS, as well as any additional important details.

Please provide date of onset and cessation of CHANGES IN BLOOD PRESSURE, as well as any additional important details.

Please provide date of onset and cessation of SKIN RASH, as well as any additional important details (including the location).

Please provide date of onset and cessation of PAIN, as well as any additional important details (including the location).

Please provide date of onset and cessation of EDEMA, as well as any additional important details (including the location).

Please provide date of onset and cessation of NUMBNESS, as well as any additional important details (including the location).

Please provide date of onset and cessation of WEAKNESS, as well as any additional important details.

Please provide date of onset and cessation of DIFFICULTY BREATHING, as well as any additional important details.

Please provide date of onset and cessation of OTHER symptom(s), as well as any additional important details.

CLINICAL INFORMATION

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

Yes

Name of Healthcare Provider and/or Medical Facility

Date of Visit

Contact Information of Healthcare Provider and/or Medical Facility

Were clinical specimens taken?

Yes

Please provide details about the type of specimen taken.

Was a formal diagnosis made?

Yes

Please provide details of the diagnosis.

OTHER EXPOSURES

Please check all that apply:

Recent Travel

Recent Consumption of Untreated Water

Recent Exposure to Untreated Water

Other Exposures

Please provide the location and date of RECENT TRAVEL.

Please provide the date and any additional details about RECENT CONSUMPTION OF UNTREATED WATER.

Please provide the date and any additional details about RECENT EXPOSURE TO UNTREATED WATER.

Please provide the date and any additional details about OTHER EXPOSURES.

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

Yes

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

Yes

May we contact whoever submitted this report for more information?

Yes

Please provide your contact information.

Enter your email address here if you would like a copy of this submission

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First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and acknowledge that I am submitting this information to the Maryland Medical Cannabis Commission as part of a serious adverse event investigation.