Fill in as much information as possible and send in the report even if you do not have all the information. You can fill this form out yourself or have someone fill it out for you. If you need help, you may want to talk with your health professional.
The FDA recognizes that privacy is an important concern, so you should know:

- We ask only for the name and contact information of the person filling out the form in case we need more information.

- Your name and contact information may be shared with the company that makes the product to help them better understand the problem you are reporting, unless you request otherwise. (See question 8 below to indicate if you do not want the FDA to share your information with the manufacturer.)

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* 1. Contact Information of Reporting Party

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* 2. Date of Incident (please estimate if you do not recall the precise date)

Date / Time

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* 3. Tell us what happened and how it happened. Please describe the sesame reaction in as much detail as possible. 

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* 4. If emergency treatment was provided, please list the doctor or hospital.

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* 5. Name and address of the store where the product was purchased.

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* 6. Please describe the product as completely as possible, including any codes or identifying marks on the label or container. 

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* 7. How long after consuming the product did the reaction occur?

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* 8. What other foods (if known) were consumed in the same time period?

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* 9. Was sesame (seeds, oil, or spice) declared on the product label?

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* 10. If you have any photos of product, labels, ingredient statement, lot codes, etc., please upload them here. 

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 11. Would you want your identity shared with the manufacturer?

About the Patient

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* 12. Person's Initials

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* 13. Sex

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* 14. Age or Date of Birth

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* 15. Ethnicity

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* 16. Race

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* 17. Has the person been diagnosed by a physician with sesame allergy?

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* 18. Please list all allergies:
(such as to drugs, foods, pollen, or others)

T