source: FOIAVistA/tag/r/ADVERSE_REACTION_TRACKING-GMRA-GMA/GMRAFN5.m@ 636

Last change on this file since 636 was 628, checked in by George Lilly, 14 years ago

initial load of FOIAVistA 6/30/08 version
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1GMRAFN5 ;HIRMFO/WAA-FDA MEDWATCH FORM ;11/30/95 15:36
2 ;;4.0;Adverse Reaction Tracking;;Mar 29, 1996
3 S GMRAX=$G(^GMR(120.85,GMRAPA1,"RPT"))
4 W ?66,"|1. Name, address & phone #: " I GMRAPG1=1 W $P(GMRAX,U)
5 W !,$E(LINE2,1,66),"|" I GMRAPG1=1 W $E($P(GMRAX,U,2)_" "_$P(GMRAX,U,3)_" "_$P(GMRAX,U,4),1,63)
6 W !,?66,"|" I GMRAPG1=1 W $E($P(GMRAX,U,5),1,63) W:$P(GMRAX,U,6)'="" ", ",$P(^DIC(5,$P(GMRAX,U,6),0),U)," " W:$P(GMRAX,U,7)'="" $P(GMRAX,U,7) W " ",$P(GMRAX,U,8)
7 W !,"Mail to: MedWatch or FAX to:",?66,"|",$E(LINE1,68,131)
8 W !," 5600 Fishers Lane 1-800-FDA-0178",?66,"|2. Health professional? |3. Occupation |4. Reported to Mfr."
9 W !," Rockville, MD 20852-9787",?66,"|"
10 I GMRAPG1=1 W ?70,"[",$S($P(GMRAX,U,9)="n":"NO",$P(GMRAX,U,9)="y":"YES",1:" "),"]"
11 W ?91,"|" I GMRAPG1=1 W $E($P(GMRAX,U,11),1,14)
12 W ?106,"|" I GMRAPG1=1 W ?110,"[",$S($P($G(^GMR(120.85,GMRAPA1,"PTC1")),U,7)'="":"YES",1:"NO"),"]"
13 W !,?66,"|",$E(LINE1,68,131)
14 W !,?66,"|5. If you don't want your identity disclosed to the Manufacturer,"
15 W !,?66,"| place an ""X"" in the box.["
16 I GMRAPG1=1 W $S($P(GMRAX,U,10)="n":"X",1:" "),"]"
17 I GMRAPG1'=1 W " ]"
18 W !,"FDA Form 3500",?66,"|",$E(LINE2,68,131)
19 W !!,"Submission of a report does not constitute an admission that medical personnel or the product caused or contributed to the event."
20 W @IOF
21 Q
22CONCO ;PRINT CONCOMITANT DRUG DATA
23 S GMRAX=$G(^TMP($J,"GMR","C",GMRACCT)) K ^TMP($J,"GMR","C",GMRACCT)
24 W " ",$P(GMRAX,U)," " I $P(GMRAX,U,2)'="" W $E($P(GMRAX,U,2),4,5),"/",$E($P(GMRAX,U,2),6,7),"/",$E($P(GMRAX,U,2),2,3)
25 I $P(GMRAX,U,3)'="" W "-",$E($P(GMRAX,U,3),4,5),"/",$E($P(GMRAX,U,3),6,7),"/",$E($P(GMRAX,U,3),2,3)
26 K GMRAX
27 I '$D(^TMP($J,"GMR","C",(GMRACCT+1))) S GMRANOC=0
28 Q
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