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This screen is for recording information about the adverse reaction. If the adverse reaction occurred in more than one person, please fill in separate reports for each person.

Please enter as much information as possible. Fields marked with a * are required.

* Date of Reaction:
Reaction Duration:

(numeric values only)
Reaction Duration Unit:

No. of People Exposed:
(numeric values only)
No. of Animals  Treated:
(numeric values only)
Species Treated:
Time to Onset:
* Description of  Reaction:
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