ReportADeviceProblem Report a Device Problem An asterisk (*) denotes a required field. Date RadDatePicker RadDatePicker Open the calendar popup. Calendar Title and navigation Title and navigation <<<January 2019><< January 2019 SMTWTFS 53303112345 26789101112 313141516171819 420212223242526 5272829303112 63456789 Title Dr. Mr. Mrs. Ms. * Name * Organization * Address 1 Address 2 * City * State/Province select - Enter Text or Select from List - AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * Zip Code or Postal Code * Telephone Fax * E-Mail Website URL May we identify you to the manufacturer and/or supplier of the device(s) involved? YesNo Device Identification Please be as specific as possible in identifying the devices involved. Please add any other information that might be helpful, and omit items that are not known or that appear to be irrelevant to this particular problem. * Type(s) of Device(s) involved * Manufacturer Model Serial/Lot No Expiration/Use before Date RadDatePicker RadDatePicker Open the calendar popup. Calendar Title and navigation Title and navigation <<<January 2019><< January 2019 SMTWTFS 53303112345 26789101112 313141516171819 420212223242526 5272829303112 63456789 How Long in use Condition Date Last Inspected or Serviced RadDatePicker RadDatePicker Open the calendar popup. Calendar Title and navigation Title and navigation <<<January 2019><< January 2019 SMTWTFS 53303112345 26789101112 313141516171819 420212223242526 5272829303112 63456789 Date Problem Occured RadDatePicker RadDatePicker Open the calendar popup. Calendar Title and navigation Title and navigation <<<January 2019><< January 2019 SMTWTFS 53303112345 26789101112 313141516171819 420212223242526 5272829303112 63456789 If requested, will you send the affected device to ECRI Institute for examination? YesNo Were other devices or accessories involved? YesNo If yes, please describe: Are other units of the same model similarly affected? YesNo If a single-use device was involved, had it been reprocessed at any time before the incident? YesNo Problem Description Could (or did) the described problem result in injury? YesNo * Please use the following text box to describe the hazard or problem in detail. Include how it was discovered, any action you took, and the response of any suppliers or manufacturers. Please also mail or fax any related correspondence, when possible. Sketches, photographs, or copies of portions of operating manuals are often helpful in describing the problem, especially if the affected device is not available for examination at ECRI Institute. Retain all disposable accessories involved in an incident. Please do not send any device to ECRI Institute until requested. Submit