Date*
Classification: * DeathUnexpected serious deterioration in healthAll other reportable events
Name*
Contact*
Adress*
Postal code / City*
Country*
Phone*
Fax
Email*
Trade name*
Model*
Catalogue number*
Serial number*
Lot Nr.*
Purchased on*
Supplied by*
Supplied on*
First time use*
First time reprocessed*
Qty of products affected*
Date of incidence*
Detailed desription*
Where is the product now?*
User of the medical device at the time of the incident* professional userPatientOther
Use of the medical device* First applicationReuse of a disposable productReuse of a reusable medical deviceDefect / problem detected before applicationServiced or repaired medical deviceOther
Short- and long-term consequences of the incident for the patient*
Gender (if relevant) malefemaleother
Age of the patient at the time of the incident
Weight in kilograms (if relevant)
Contact person*
ZIP / City*
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