Report a Device Problem

Date

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Title

* Name

* Organization

* Address 1

Address 2

* City

* State/Province

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* 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?

Yes
No

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

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How Long in use

Condition

Date Last Inspected or Serviced

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Date Problem Occured

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If requested, will you send the affected device to ECRI Institute for examination?

Yes
No

Were other devices or accessories involved?

Yes
No
If yes, please describe:

Are other units of the same model similarly affected?

Yes
No

If a single-use device was involved, had it been reprocessed at any time before the incident?

Yes
No

Problem Description

Could (or did) the described problem result in injury?

Yes
No

* 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.

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