EUA for Chloroquine Phosphate or Hydroxychloroquine Sulfate Supplied from the Strategic National Stockpile
To be completed upon patient disposition
Provide the name of the prescribing health care provider, phone number and email
Provide the name of the prescribing health care provider, phone number and email
Provide the hospital name, city and state where the patient was admitted and treated for COVID-19.
Provide the hospital name, city and state where the patient was admitted and treated for COVID-19.
Provide the patient age
Provide the patient age
Provide the patient sex
Please select the patient's underlying conditions, as applicable.
Please select the patient's underlying conditions, as applicable.
 
*Which Strategic National Stockpile medication was administered (Hydroxychloroquine or Chloroquine)?
How many days of dosing did the patient receive (approximately)?
How many days of dosing did the patient receive (approximately)?
*Estimation of severity of illness immediately prior to treatment.
Number of Days of Hospital Stay (approximately)
Number of Days of Hospital Stay (approximately)
*Disposition of patient
Related Serious Adverse Events (SAEs) of Special InterestIf a drug related SAE, please complete Medwatch form ( www.fda.gov/medwatch/report.htm ) and submit to FDA (if not already completed).
Related Serious Adverse Events (SAEs) of Special Interest

If a drug related SAE, please complete Medwatch form ( www.fda.gov/medwatch/report.htm and submit to FDA (if not already completed).