ADVERSE
EVENT
REPORTING

In case of any adverse event related to the Covie App, please fill out the form.

What kind of problem was it? (Check all that apply)

Were hurt or had a bad side effect (including new or worsening symptoms)

Used a product incorrectly which could have or led to a problem

Noticed a problem with the quality of the product

Had problems after switching from one product maker to another maker

Did any of the following happen? (Check all that apply)

Hospitalization - admitted or stayed longer

Required help to prevent permanent harm

Disability or health problem

Birth defect

Life-threatening

Death

Other serious/important medical incident

Date the Problem Occurred

Tell us what happened and how it happened

Who is the reporter of this problem?

User

Caregiver

Healthcare professional

Reporters Initials

Reporter Date of Birth

Any other comments

Thanks for sharing with us!

Covie is a Covid-19 early detection awareness program.
It is developed to alert the Covid-19 patients prior to symptom occurrence.

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