Incident Form

Type   Incident

Company  

Account Code:  

Contact Name  

Phone  

Email  




Type of Incident:   --None--Product Complaint Repair Service Install Out of Box Failure Mislabeled Product Shipping Damage Distribution Center Error Customer Dissatisfaction

Date of report:  

Alleged Incident Date:  

Facility Address:  

Reporting Persons Name and Title:  

Reporting Persons phone# and/or email:  




Product Name:  

Reorder #:  

Expiration Date:  

Quantity:  

Unit of Measure: --None-- Box Case Single Unit

Purchase Order/Invoice #:  

Invoice or SO#, If Available:  




Brand Name:  

Description of Product (as it appears on):  

Intended Use (as it appears on label):  

Batch/Lot No.:  

Serial Number:  

Product Returned:   --None-- Yes No

Did you return the product?:   --None-- Yes No

Did any of the following happen?:   Hospitalization - admitted or stayed longer   Required help to prevent permanent harm   Disability or health problem   Birth defect   Life-threatening   Death   Other serious/important medical incident  

Date the problem occurred (mm/dd/yyyy):  

Tell us what happened and how it happened*:  

Medical or Procedural Intervention?*:   --None-- Yes No




Relevant Tests/Laboratory Data:

Test Date:  
Test Name:  
Test Unit:  
Test Result:  
Low Test Range:  
High Test Range:  

Additional Comments:  



Please select the cause of the problem that applies below:
">--None--For a problem with an over the counter product For a problem with a medical device.

If it's a medical device, select any that apply:
--None-- any health-related test, tool, or piece of equipment health-related kits, such as glucose monitoring kits or blood pressure cuffs implants, such as breast implants, pacemakers, or catheters other health products, such as contact lenses, hearing aids, and breast pumps  

Do you still have the product in case we need to evaluate it?:   --None-- Yes No

Do you have a picture of the product/defect? :   --None-- Yes No