RECORDREFERENCE OUTLINE

Individual Case Safety Report Processing Record

Case-processing record built around the decision that actually gets cited in findings: day zero and how awareness is evidenced. Covers minimum criteria, seriousness and expectedness against a named labelling version, coding with dictionary versions, follow-up attempts, and per-authority submission with acknowledgements. Maps to ICH E2A, E2B(R3) and E2D(R1).

What a template is not

A template is a document baseline to adapt inside your own quality system. SPEQ does not approve, validate, or take responsibility for what you issue from it, and using one is not evidence of compliance.

CHECKING ACCESS

Checking your Professional access…

REGULATIONS MAPPED
ICH E2AICH E2B(R3)ICH E2D(R1)EU GVP Modules
DOCUMENT TYPE
Record
LAST UPDATED
August 2026
PURPOSE

An Individual Case Safety Report is the atomic unit of pharmacovigilance: one patient, one or more suspected adverse reactions, one reporting obligation with a clock attached. The hard part is not the form — it is deciding the day zero from which the clock runs and defending that decision months later, because day zero depends on when your organisation first held the information, not when the case file was opened.

What's Inside

Awareness and day zero, with the record that evidences when the information was first held
Minimum-criteria check recording what was actually captured for each of the required elements
Seriousness, expectedness and both causality assessments, each carrying the basis for the judgement
Coding table showing the dictionary version applied to every coded element in the case
Follow-up attempt log recording what was sought, from whom, when, and with what result
Per-authority submission table with acknowledgement references, since the obligation differs from one territory to another
Closure entry stating why no further follow-up is being pursued on this particular case

How to Use It

1Take day zero from the date any part of the organisation first received the minimum information, including a contracted party or commercial function.
2Name the reference safety information version you judged expectedness against; a draft or superseded label is a recurring finding.
3Do not discard a case failing a minimum criterion — record it, pursue the missing element, and keep the original awareness date.
4Record the dictionary version used for coding, or the case cannot be re-assessed consistently after a dictionary update.
5Seek follow-up before the clock expires; a submitted case with documented unsuccessful attempts is defensible, a late one awaiting information is not.
6Record the acknowledgement for each authority separately, because a transmission accepted in one territory proves nothing about another.
DOCUMENT CONTENTS

The full section structure of this template — every section and sub-section, so you can use it as a baseline for your own site document.

Document Control
Document InformationApproval SignaturesRevision HistoryDistribution List
1Awareness and Day Zero
2Minimum Criteria
3Assessment
4Coding and Narrative
Case narrative
5Follow-Up
6Submission and Closure
REGULATORY CONTEXT

ICH E2A defines expedited reporting with the seriousness and expectedness concepts, ICH E2B(R3) the electronic transmission format, ICH E2D(R1) post-approval awareness and day zero, and EU GVP Module VI the collection and submission of individual case safety reports for EU-authorised products. None of them decides when your particular organisation became aware, or which internal receipt counts — that determination is yours and rests on the intake records you keep. The record structure is SPEQ’s practitioner synthesis.

MAPPED STANDARDS
ICH E2AICH E2B(R3)ICH E2D(R1)EU GVP Modules
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