Local Drug Information System (LDIS) Reporting Form

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

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

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

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

If available, please attached a photograph (next to coin for scale), or any other relevant documents

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

Effect of drug: any observed effect(s) or the effect(s) as described to you (if known) 

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

Any other information