{"id":4656,"date":"2026-09-05T00:06:33","date_gmt":"2026-09-04T22:06:33","guid":{"rendered":"https:\/\/www.actpharma-sa.com\/?page_id=4656"},"modified":"2026-09-06T02:54:40","modified_gmt":"2026-09-06T00:54:40","slug":"rapporter-un-evenement-indesirable","status":"publish","type":"page","link":"https:\/\/www.actpharma-sa.com\/en\/rapporter-un-evenement-indesirable\/","title":{"rendered":"Rapporter un \u00e9v\u00e8nement ind\u00e9sirable"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_2' style='display:none'><a id='gf_2' class='gform_anchor' ><\/a><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/4656#gf_2'><div class=\"inv-recaptcha-holder\"><\/div>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>D\u00e9claration d'effet ind\u00e9sirable<\/h3>\n                            <span class='gform_description'><\/span>\n                        <\/div>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 5\n        <\/h3>\n            <div class='gf_progressbar'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_2_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_17'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Notificateur<\/h2><\/li><li id='field_2_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_4' >Nom<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_5'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_5' >Pr\u00e9nom<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_38'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_38' >Qualification\/sp\u00e9cialit\u00e9 :<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_13'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_13' >T\u00e9l\u00e9phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_2_13' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_14'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_14' >E-mail<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_2_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"\/>\n                        <\/div><\/li><li id='field_2_16'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Le notificateur est-il d&#039;accord pour \u00eatre contact\u00e9 par l&#039;unit\u00e9 de pharmacovigilance\/ d\u00e9l\u00e9gu\u00e9 ?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_16'><li class='gchoice_2_16_0'><input name='input_16' type='radio' value='Oui'  id='choice_2_16_0'     \/><label for='choice_2_16_0' id='label_2_16_0'>Oui<\/label><\/li><li class='gchoice_2_16_1'><input name='input_16' type='radio' value='Non'  id='choice_2_16_1'     \/><label for='choice_2_16_1' id='label_2_16_1'>Non<\/label><\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_2_18' class='gform_next_button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_19'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Donn\u00e9es sur le patient<\/h2><\/li><li id='field_2_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_2_21_3' >Nom et Prenom<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_2_21'>\n                            \n                            <span id='input_2_21_3_container' class='name_first' >\n                                                    <input type='text' name='input_21.3' id='input_2_21_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_21_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_21_6_container' class='name_last' >\n                                                    <input type='text' name='input_21.6' id='input_2_21_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_2_21_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_2_22'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_22' >Date de naissance<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_22' id='input_2_22' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_22' class='gform_hidden' value='https:\/\/www.actpharma-sa.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_2_23'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Sexe<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_23'><li class='gchoice_2_23_0'><input name='input_23' type='radio' value='M'  id='choice_2_23_0'   onclick='gf_apply_rules(2,[26,28,29,31,33]);' onkeypress='gf_apply_rules(2,[26,28,29,31,33]);'  \/><label for='choice_2_23_0' id='label_2_23_0'>M<\/label><\/li><li class='gchoice_2_23_1'><input name='input_23' type='radio' value='F'  id='choice_2_23_1'   onclick='gf_apply_rules(2,[26,28,29,31,33]);' onkeypress='gf_apply_rules(2,[26,28,29,31,33]);'  \/><label for='choice_2_23_1' id='label_2_23_1'>F<\/label><\/li><\/ul><\/div><\/li><li id='field_2_24'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_24' >Poids<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'>kg<\/div><\/li><li id='field_2_25'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_25' >Taille<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'>m<\/div><\/li><li id='field_2_26'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Grossesse<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_26'><li class='gchoice_2_26_0'><input name='input_26' type='radio' value='Oui'  id='choice_2_26_0'     \/><label for='choice_2_26_0' id='label_2_26_0'>Oui<\/label><\/li><li class='gchoice_2_26_1'><input name='input_26' type='radio' value='Non'  id='choice_2_26_1'     \/><label for='choice_2_26_1' id='label_2_26_1'>Non<\/label><\/li><\/ul><\/div><\/li><li id='field_2_28'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_28' >Si oui, date des derni\u00e8res r\u00e8gles<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_2_28' type='text' value='' class='datepicker medium mdy datepicker_with_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_28' class='gform_hidden' value='https:\/\/www.actpharma-sa.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_2_29'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Trimestre de grossesse<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_29'><li class='gchoice_2_29_0'><input name='input_29' type='radio' value='1er trimestre'  id='choice_2_29_0'     \/><label for='choice_2_29_0' id='label_2_29_0'>1er trimestre<\/label><\/li><li class='gchoice_2_29_1'><input name='input_29' type='radio' value='2\u00e8me trimestre'  id='choice_2_29_1'     \/><label for='choice_2_29_1' id='label_2_29_1'>2\u00e8me trimestre<\/label><\/li><li class='gchoice_2_29_2'><input name='input_29' type='radio' value='3\u00e8me trimestre'  id='choice_2_29_2'     \/><label for='choice_2_29_2' id='label_2_29_2'>3\u00e8me trimestre<\/label><\/li><\/ul><\/div><\/li><li id='field_2_31'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Allaitement<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_31'><li class='gchoice_2_31_0'><input name='input_31' type='radio' value='Oui'  id='choice_2_31_0'     \/><label for='choice_2_31_0' id='label_2_31_0'>Oui<\/label><\/li><li class='gchoice_2_31_1'><input name='input_31' type='radio' value='Non'  id='choice_2_31_1'     \/><label for='choice_2_31_1' id='label_2_31_1'>Non<\/label><\/li><\/ul><\/div><\/li><li id='field_2_33'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >S&#039;il s&#039;agit d&#039;un nouveau-n\u00e9, le m\u00e9dicament a \u00e9t\u00e9 pris :<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_33'><li class='gchoice_2_33_1'>\n\t\t\t\t\t\t\t\t<input name='input_33.1' type='checkbox'  value='Par le nouveau-n\u00e9'  id='choice_2_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1'>Par le nouveau-n\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_33_2'>\n\t\t\t\t\t\t\t\t<input name='input_33.2' type='checkbox'  value='Lors de l&#039;allaitement'  id='choice_2_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_2' id='label_2_33_2'>Lors de l'allaitement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_33_3'>\n\t\t\t\t\t\t\t\t<input name='input_33.3' type='checkbox'  value='Par la m\u00e8re durant sa grossesse'  id='choice_2_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_3' id='label_2_33_3'>Par la m\u00e8re durant sa grossesse<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_2_34'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Facteurs de risques et Ant\u00e9c\u00e9dents<\/h2><\/li><li id='field_2_36'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Facteurs de risque<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_36'><li class='gchoice_2_36_1'>\n\t\t\t\t\t\t\t\t<input name='input_36.1' type='checkbox'  value='Tabac'  id='choice_2_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_1' id='label_2_36_1'>Tabac<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_2'>\n\t\t\t\t\t\t\t\t<input name='input_36.2' type='checkbox'  value='Alcool'  id='choice_2_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_2' id='label_2_36_2'>Alcool<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_3'>\n\t\t\t\t\t\t\t\t<input name='input_36.3' type='checkbox'  value='Drogues'  id='choice_2_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_3' id='label_2_36_3'>Drogues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_4'>\n\t\t\t\t\t\t\t\t<input name='input_36.4' type='checkbox'  value='Radioth\u00e9rapie'  id='choice_2_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_4' id='label_2_36_4'>Radioth\u00e9rapie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_5'>\n\t\t\t\t\t\t\t\t<input name='input_36.5' type='checkbox'  value='Implants'  id='choice_2_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_5' id='label_2_36_5'>Implants<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_6'>\n\t\t\t\t\t\t\t\t<input name='input_36.6' type='checkbox'  value='Contraception hormonale'  id='choice_2_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_6' id='label_2_36_6'>Contraception hormonale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_36_7'>\n\t\t\t\t\t\t\t\t<input name='input_36.7' type='checkbox'  value='Autres'  id='choice_2_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_7' id='label_2_36_7'>Autres<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_2_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_37' >Ant\u00e9c\u00e9dents du patient<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_39' class='gform_previous_button button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_39' class='gform_next_button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_41'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Donn\u00e9es sur le(s) m\u00e9dicament(s) pris par le patient<\/h2><\/li><li id='field_2_40'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_40' >M\u00e9dicament<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_44'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_44' >Sans titre<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_42'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_42' >DCI<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_2_42' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><div class='gfield_description'>D\u00e9nomination Commune Internationale<\/div><\/li><li id='field_2_43'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_43' >Posologie<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_45'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_45' >N\u00b0 de lot<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_47'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_47' >D\u00e9but d\u2019utilisation<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_48'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_48' >Fin d\u2019utilisation<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_49'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_49' >Pourquoi ce m\u00e9dicament a-t-il \u00e9t\u00e9 pris?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_2_49' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_50' class='gform_previous_button button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_50' class='gform_next_button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_51'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Donn\u00e9es sur le(s) \u00e9v\u00e9nement(s) ind\u00e9sirable(s)<\/h2><\/li><li id='field_2_54'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_54' >Date d&#039;apparition :<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_54' id='input_2_54' type='text' value='' class='datepicker medium mdy datepicker_with_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_54' class='gform_hidden' value='https:\/\/www.actpharma-sa.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_2_55'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_55' >Dur\u00e9e:<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_53'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_53' >Description d\u00e9taill\u00e9e de l\u2019effet ind\u00e9sirable observ\u00e9 :<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_2_53' class='textarea medium'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_2_56'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gravit\u00e9 :<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_56'><li class='gchoice_2_56_1'>\n\t\t\t\t\t\t\t\t<input name='input_56.1' type='checkbox'  value='Hospitalisation ou prolongation d&#039;hospitalisation'  id='choice_2_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_1' id='label_2_56_1'>Hospitalisation ou prolongation d'hospitalisation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_56_2'>\n\t\t\t\t\t\t\t\t<input name='input_56.2' type='checkbox'  value='Incapacit\u00e9 ou invalidit\u00e9 permanente'  id='choice_2_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_2' id='label_2_56_2'>Incapacit\u00e9 ou invalidit\u00e9 permanente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_56_3'>\n\t\t\t\t\t\t\t\t<input name='input_56.3' type='checkbox'  value='Mise en jeu du pronostic vital'  id='choice_2_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_3' id='label_2_56_3'>Mise en jeu du pronostic vital<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_56_4'>\n\t\t\t\t\t\t\t\t<input name='input_56.4' type='checkbox'  value='D\u00e9c\u00e8s'  id='choice_2_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_4' id='label_2_56_4'>D\u00e9c\u00e8s<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_56_5'>\n\t\t\t\t\t\t\t\t<input name='input_56.5' type='checkbox'  value='Anomalie ou malformation cong\u00e9nitale'  id='choice_2_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_5' id='label_2_56_5'>Anomalie ou malformation cong\u00e9nitale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_56_6'>\n\t\t\t\t\t\t\t\t<input name='input_56.6' type='checkbox'  value='Non grave'  id='choice_2_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_6' id='label_2_56_6'>Non grave<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_2_57'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Evolution :<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_57'><li class='gchoice_2_57_1'>\n\t\t\t\t\t\t\t\t<input name='input_57.1' type='checkbox'  value='Gu\u00e9rison sans s\u00e9quelle'  id='choice_2_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1'>Gu\u00e9rison sans s\u00e9quelle<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_2'>\n\t\t\t\t\t\t\t\t<input name='input_57.2' type='checkbox'  value='Gu\u00e9rison avec s\u00e9quelles'  id='choice_2_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_2' id='label_2_57_2'>Gu\u00e9rison avec s\u00e9quelles<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_3'>\n\t\t\t\t\t\t\t\t<input name='input_57.3' type='checkbox'  value='Gu\u00e9rison en cours'  id='choice_2_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_3' id='label_2_57_3'>Gu\u00e9rison en cours<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_4'>\n\t\t\t\t\t\t\t\t<input name='input_57.4' type='checkbox'  value='Sujet non encore r\u00e9tabli'  id='choice_2_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_4' id='label_2_57_4'>Sujet non encore r\u00e9tabli<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_5'>\n\t\t\t\t\t\t\t\t<input name='input_57.5' type='checkbox'  value='D\u00e9c\u00e8s d\u00fb \u00e0 l&#039;effet'  id='choice_2_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_5' id='label_2_57_5'>D\u00e9c\u00e8s d\u00fb \u00e0 l'effet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_6'>\n\t\t\t\t\t\t\t\t<input name='input_57.6' type='checkbox'  value='D\u00e9c\u00e8s sans rapport avec l&#039;effet'  id='choice_2_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_6' id='label_2_57_6'>D\u00e9c\u00e8s sans rapport avec l'effet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_57_7'>\n\t\t\t\t\t\t\t\t<input name='input_57.7' type='checkbox'  value='Inconnue'  id='choice_2_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_57_7' id='label_2_57_7'>Inconnue<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_2_58'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Condition de survenue :<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_58'><li class='gchoice_2_58_1'>\n\t\t\t\t\t\t\t\t<input name='input_58.1' type='checkbox'  value='conditions normales d&#039;utilisation'  id='choice_2_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1'>conditions normales d'utilisation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_58_2'>\n\t\t\t\t\t\t\t\t<input name='input_58.2' type='checkbox'  value='Erreur m\u00e9dicamenteuse'  id='choice_2_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_2' id='label_2_58_2'>Erreur m\u00e9dicamenteuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_58_3'>\n\t\t\t\t\t\t\t\t<input name='input_58.3' type='checkbox'  value='M\u00e9susage'  id='choice_2_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_3' id='label_2_58_3'>M\u00e9susage<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_58_4'>\n\t\t\t\t\t\t\t\t<input name='input_58.4' type='checkbox'  value='Surdosage'  id='choice_2_58_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_4' id='label_2_58_4'>Surdosage<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_58_5'>\n\t\t\t\t\t\t\t\t<input name='input_58.5' type='checkbox'  value='Abus'  id='choice_2_58_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_5' id='label_2_58_5'>Abus<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_58_6'>\n\t\t\t\t\t\t\t\t<input name='input_58.6' type='checkbox'  value='Autre'  id='choice_2_58_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_58_6' id='label_2_58_6'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_2_59'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Y-a-t-il eu disparition de(s) effet\/\u00e9v\u00e9nement(s) \u00e0 l&#039;arr\u00eat du m\u00e9dicament :<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'><li class='gchoice_2_59_0'><input name='input_59' type='radio' value='Oui'  id='choice_2_59_0'     \/><label for='choice_2_59_0' id='label_2_59_0'>Oui<\/label><\/li><li class='gchoice_2_59_1'><input name='input_59' type='radio' value='Non'  id='choice_2_59_1'     \/><label for='choice_2_59_1' id='label_2_59_1'>Non<\/label><\/li><\/ul><\/div><\/li><li id='field_2_60'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >R\u00e9apparition de(s) effet\/\u00e9v\u00e8nement(s) \u00e0 la reprise du m\u00e9dicament :<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_60'><li class='gchoice_2_60_0'><input name='input_60' type='radio' value='Oui'  id='choice_2_60_0'     \/><label for='choice_2_60_0' id='label_2_60_0'>Oui<\/label><\/li><li class='gchoice_2_60_1'><input name='input_60' type='radio' value='Non'  id='choice_2_60_1'     \/><label for='choice_2_60_1' id='label_2_60_1'>Non<\/label><\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_2_61' class='gform_previous_button button' value='Pr\u00e9c\u00e9dent'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_61' class='gform_next_button button' value='Suivant'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_62'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Coordonn\u00e9es du d\u00e9clarant :<\/h2><\/li><li id='field_2_63'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_63' >Nom et pr\u00e9nom :<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_2_63' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_65'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_65' >Poste\/ service, Direction :<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_2_65' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_68'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_2_68_1' >Adresse<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gfield_trigger_change' id='input_2_68' >\n                         <span class='ginput_full address_line_1' id='input_2_68_1_container' >\n                                        <input type='text' name='input_68.1' id='input_2_68_1' value=''   \/>\n                                        <label for='input_2_68_1' id='input_2_68_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_2_68_3_container' >\n                                    <input type='text' name='input_68.3' id='input_2_68_3' value=''   \/>\n                                    <label for='input_2_68_3' id='input_2_68_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_2_68_4_container' >\n                                        <input type='text' name='input_68.4' id='input_2_68_4' value=''     \/>\n                                        <label for='input_2_68_4' id='input_2_68_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_2_68_5_container' >\n                                    <input type='text' name='input_68.5' id='input_2_68_5' value=''   \/>\n                                    <label for='input_2_68_5' id='input_2_68_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_2_68_6_container' >\n                                        <select name='input_68.6' id='input_2_68_6'  ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' 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