Please complete the Safety Event report below

This adverse event report form is available to report an adverse event or other special situation event, including pregnancy; overdose; suspected abuse/misuse; inadvertent or accidental exposure; medication error; lack of effect, use of Rytelo (Imetelstat) with pediatric or elderly population (or “use of Rytelo (Imetelstat) in age groups outside the age range approved within the product label” OR “off-label use”), exposure to Imetelstat during breastfeeding that occurred during or after treatment with Imetelstat.

Note: If the patient experiencing the adverse event is participating in an active Geron Imetelstat clinical trial, please contact your investigative site to report an adverse event.

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Fields marked like this * are required to submit a report. Data entry can be performed either by typing or by voice entry by clicking on the microphone icon.

Geron Reporter

Are you a Geron employee or agent of Geron? (Yes/No)^*

Reporter

First Name

Last Name

Reporter Qualification^*

Consent for follow-up: Reporter agrees to be contacted by Geron or its agents regarding follow-up on the reported safety event (Yes/No)^*

Patient

Patient age or patient age group (when event occurred)^*

Patient Age In Years^*

Patient Age Group^*

Sex at birth

Safety Event(s)

Brief description of the Safety Event (summary of safety event, including details, tests, treatments, hospitalization, and outcome). If patient is a subject in a clinical trial, include trial identification^*

Start Date

Ended or Ongoing

If ended, please provide the date

Product(s)

Product Name^*

Please complete the Safety Event report below

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Mandatory Data Missing/Data Correction

Success !

Failure !