Download ESI forms

All of these forms have been updated to the latest version (2015). If you are unsure which ESI form you need, please contact the PV team on 0161 306 1911 who will be happy to advise.

Please note, while these forms are available to download, they must be filled in directly on the database after entering the corresponding adverse events. The database now allows multiple ESI forms to be attached to a single adverse event, so don't worry about choosing only one if the event can be categorised as more than one ESI.

Please see the Entering ESI forms section for more information on how to enter them onto the database.

• Aplastic anaemia, pancytopaenia, serious neutropenia
• Cerebrovascular Accident (CVA)
• Hepatitis B Reactivation
• Lymphoproliferative Disease
• Malignancy (not including skin)
• Melanoma Or Skin Cancer including Bowens Disease
• Myocardial Infarction/Acute Coronary Disease
• Pregnancy
• Pulmonary Embolism
• Serious Congestive Heart Failure
• Serious Demyelination/Optic Neuritis
• Serious Hepatic Dysfunction/Failure
• Serious Hypersensitivity Reaction
• Serious Infection (excl. TB)
• Serious Lupus/Lupus like illness
• Serious Psoriasis Flare - this is only required if the patient was hospitalised overnight
• Serious Skin Reaction (e.g. Stevens Johnson syndrome, erythema multiforme toxic epidermal necrosis)
• Surgery (Overnight Hospitalisation)
• Tuberculosis (Not Latent)