Local Drug Information System (LDIS) Reporting Form

1.  

Your contact details: role and service where appropriate

4.  

Effect of drug: the effect as described to you (if known)

5.  

Name of drug: if known, indicate if brand name on packet, street name, chemical name etc.

6.  

How was the effect different from what was expected? (e.g. lasted longer, was more potent)

8.  

Concern: please indicate concern (i.e. adverse effect, altered behaviour, violence, overdose, multiple reports)

9.  

Dosage: how much was taken; if more than one type of drug please list amount for each

10.  

Cost: please specify if price is for weight, per bag, pill etc

12.  

Appearance of drug: (i.e.. white powder, pill) 

14.  

If available, please attached a photograph (next to coin for scale)

16.  

Any other information