|The use of essential drugs: Eight report of the WHO Expert Committee (WHO, 1998, 84 p.)|
1 A summary (maximum 3 pages) of relevant background information should be attached, together with relevant literature to support the therapeutic use.
Name of responsible officer:
Contact person (if submitted by an organization):
We hereby request the World Health Organization to consider the following pharmaceutical product for inclusion in the WHO Model List of Essential Drugs
Signature _________________________ Date________________________
Name of drug (INN and trade name):
Dosage form and strength:
Why is this drug being proposed for inclusion in the list?
Please state how it conforms to the criteria for inclusion as an essential drug:
Please provide evidence of efficacy (with references):
If a therapeutic class for this drug already exists in the list, please summarize the advantages of this product:
Describe the drugs pharmacokinetics:
List any contraindications, precautions and toxic effects:
Is this drug available as a generic product?
Please state any restrictions on the use of this drug. Should a note be included in the list regarding its use?