Pfizer Incorporated

SERBIA/ Drug Safety Unit

CONTACT REPORT FOR

Product / dosage form: AER number: Address / telephone / fax #:

Person contacted:

Pfizer Received Date:

Safet Received Date !Date of "ontact#$:

"RA

%nvestigator

Ph sician

Pharmacist

"onsumer

&ther:

'ode of contact: (elephone Summar of discussions:

Personal visit

&ther: +o

"onsent for further DS) contact obtained: *es

+ot applicable

,oicemail (ranscript "ertification: (Section applicable only to voicemails) % hereb certif that the data transcribed from the voicemail recording into this formaccuratel and completel reflect the information that had been recorded

+ot applicable Signature: Preparer of the report:

Date: Signature:

* Date of filling in the form . Safet Received Date !Date of "ontact# AEM01-SRB01-Form01 DSU Contact Form.doc 31-Oct-2013 Pfizer nterna! U"e