Registration of national contact person for pharmacovigilance

As a marketing authorisation holder you are required to appoint an EU Qualified Person responsible for Pharmacovigilance (QPPV). Additionally, if the QPPV is resident outside the Netherlands or does not speak and write Dutch, you are required to appoint a national contact person.

The national contact person for pharmacovigilance acts as an intermediary with the authorities, and also as the point of contact for patients and medical healthcare practitioners.

First contact person details

Salutation *

First name *

Last name *

Address *

Telephone number *

E-mail address *

Is there a second contact person? *

Yes

Previous contact person details (if applicable, e.g. no longer employed by MAH)

Salutation

First name

Last name

Name of company

Address

Second contact person details

Salutation *

First name *

Last name *

Address *

Telephone number *

E-mail address *

Specify:

back-up for first contact person (in case of absence)

responsible for part of product portfolio or group of medicinal products (please specify:…. )

Company/companies details

Name of company *

Address *

Name of company

Address

Name of company

Address

Name of company

Address

In case you are appointed as contact person for more than 4 companies, we kindly request you to submit the data in a new form.

Signature

I declare that the information provided in this form is true. *

Salutation *

First name *

Last name *

Place *

Date *

* = Input is required