Republic of Botswana - Admin

IV. CLINICIAN INFORMATION (If not the reporter): (to be confidential & used only for data
verification, completion & case follow-up)
Name & Professional Address :
Telephone No (with Country code): Specialty: Date of Report:
V. REPORTER:
Name & Professional Address :
Telephone No. (with Country code):
Date of Report:
Health professional: Yes No Occupation:
Also Reported To: No one else Manufacturer Distributor Facility used
Notification Through (Post, Facsimile, Electronic Device, etc.):
Signature:
Date:
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