{"id":2324,"date":"2023-01-09T14:41:14","date_gmt":"2023-01-09T13:41:14","guid":{"rendered":"http:\/\/wordpress.p546170.webspaceconfig.de\/?page_id=2324"},"modified":"2023-01-12T09:11:01","modified_gmt":"2023-01-12T08:11:01","slug":"meldeformular","status":"publish","type":"page","link":"https:\/\/www.elcon-medical.com\/en\/meldeformular\/","title":{"rendered":"Form incident"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: #ffffff;background-position: left top;background-repeat: no-repeat;padding-top:100px;padding-right:0px;padding-bottom:100px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 1px 0px 1px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-column-no-min-height\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><h2 class=\"fusion-responsive-typography-calculated\" style=\"text-align: center; --fontsize: 28; line-height: 1.21;\" data-fontsize=\"28\" data-lineheight=\"33.8833px\">Report form incident \/<br \/>\nnear incident to receive an emergancy number<\/h2>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator\" style=\"margin-left: auto;margin-right: auto;margin-top:10px;margin-bottom:30px;width:100%;max-width:170px;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#dfdddd;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator\" style=\"margin-left: auto;margin-right: auto;margin-top:40px;width:100%;max-width:170px;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_4 3_4 fusion-three-fourth fusion-column-first\" style=\"width:74%; margin-right: 4%;margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4034-o1\" lang=\"de-DE\" dir=\"ltr\" data-wpcf7-id=\"4034\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/2324#wpcf7-f4034-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Kontaktformular\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4034\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"de_DE\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4034-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<h2>1. Administrative Information\n<\/h2>\n<p><label>Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"datum-meldung\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"datum-meldung\" \/><\/span> <\/label>\n<\/p>\n<p><label>Classification: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"klassifizierung\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"klassifizierung\"><option value=\"Death\">Death<\/option><option value=\"Unexpected serious deterioration in health\">Unexpected serious deterioration in health<\/option><option value=\"All other reportable events\">All other reportable events<\/option><\/select><\/span> <\/label>\n<\/p>\n<h2>2. Information about the reporter\n<\/h2>\n<p><label>Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ihrname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ihrname\" \/><\/span> <\/label>\n<\/p>\n<p><label>Contact*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kontaktperson\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kontaktperson\" \/><\/span> <\/label>\n<\/p>\n<p><label>Adress*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse\" \/><\/span> <\/label>\n<\/p>\n<p><label>Postal code \/ City*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plzort\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plzort\" \/><\/span> <\/label>\n<\/p>\n<p><label>Country*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"land\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"land\" \/><\/span> <\/label>\n<\/p>\n<p><label>Phone*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"telefon\" \/><\/span> <\/label>\n<\/p>\n<p><label>Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fax\" \/><\/span> <\/label>\n<\/p>\n<p><label>Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"email\" \/><\/span> <\/label>\n<\/p>\n<h2>3. Information about the medical device\n<\/h2>\n<p><label>Trade name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Handelsname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Handelsname\" \/><\/span> <\/label>\n<\/p>\n<p><label>Model*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"modellnummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"modellnummer\" \/><\/span> <\/label>\n<\/p>\n<p><label>Catalogue number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"katalognummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"katalognummer\" \/><\/span> <\/label>\n<\/p>\n<p><label>Serial number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Seriennummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Seriennummer\" \/><\/span> <\/label>\n<\/p>\n<p><label>Lot Nr.*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lotnr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lotnr\" \/><\/span> <\/label>\n<\/p>\n<p><label>Purchased on*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gekauftam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gekauftam\" \/><\/span> <\/label>\n<\/p>\n<p><label>Supplied by*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"geliefertdurch\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"geliefertdurch\" \/><\/span> <\/label>\n<\/p>\n<p><label>Supplied on*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"geliefertam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"geliefertam\" \/><\/span> <\/label>\n<\/p>\n<p><label>First time use*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"erstmalsgenutzt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"erstmalsgenutzt\" \/><\/span> <\/label>\n<\/p>\n<p><label>First time reprocessed*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"erstmalsaufbereitet\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"erstmalsaufbereitet\" \/><\/span> <\/label>\n<\/p>\n<p><label>Qty of products affected*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"anzahl\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anzahl\" \/><\/span> <\/label>\n<\/p>\n<h2>4. Information about the incident\n<\/h2>\n<p><label>Date of incidence*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"datumVorkommnis\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"datumVorkommnis\" \/><\/span> <\/label>\n<\/p>\n<p><label>Detailed desription*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vorkommnisBeschreibung\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"vorkommnisBeschreibung\"><\/textarea><\/span><\/label>\n<\/p>\n<p><label>Where is the product now?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vorkommnisWobefindetProdukt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vorkommnisWobefindetProdukt\" \/><\/span> <\/label>\n<\/p>\n<p><label>User of the medical device at the time of the incident*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vorkommnisAnwender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"vorkommnisAnwender\"><option value=\"professional user\">professional user<\/option><option value=\"Patient\">Patient<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label>Use of the medical device*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vorkommnisVerwendung\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"vorkommnisVerwendung\"><option value=\"First application\">First application<\/option><option value=\"Reuse of a disposable product\">Reuse of a disposable product<\/option><option value=\"Reuse of a reusable medical device\">Reuse of a reusable medical device<\/option><option value=\"Defect \/ problem detected before application\">Defect \/ problem detected before application<\/option><option value=\"Serviced or repaired medical device\">Serviced or repaired medical device<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n<\/p>\n<h2>5. Patient information\n<\/h2>\n<p><label>Short- and long-term consequences of the incident for the patient*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kurzlangzeitfolgen\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"kurzlangzeitfolgen\"><\/textarea><\/span><\/label>\n<\/p>\n<p><label>Gender (if relevant)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"geschlecht\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"geschlecht\"><option value=\"male\">male<\/option><option value=\"female\">female<\/option><option value=\"other\">other<\/option><\/select><\/span><br \/>\n<\/label>\n<\/p>\n<p><label>Age of the patient at the time of the incident<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alterPatient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alterPatient\" \/><\/span> <\/label>\n<\/p>\n<p><label>Weight in kilograms (if relevant)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gewichtPatient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gewichtPatient\" \/><\/span> <\/label>\n<\/p>\n<h2>6. Health Facility Information\n<\/h2>\n<p><label>Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungName\" \/><\/span><\/label>\n<\/p>\n<p><label>Contact person*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungKontaktperson\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungKontaktperson\" \/><\/span><\/label>\n<\/p>\n<p><label>Adress*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungAdresse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungAdresse\" \/><\/span><\/label>\n<\/p>\n<p><label>ZIP \/ City*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungPlzort\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungPlzort\" \/><\/span><\/label>\n<\/p>\n<p><label>Country*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungLand\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungLand\" \/><\/span><\/label>\n<\/p>\n<p><label>Phone*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungTelefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungTelefon\" \/><\/span><\/label>\n<\/p>\n<p><label>Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungFax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungFax\" \/><\/span><\/label>\n<\/p>\n<p><label>Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitseinrichtungEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gesundheitseinrichtungEmail\" \/><\/span><\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-656\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-656\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I hereby agree to the processing of my data and the <a href=\"\/en\/data-privacy\/\" target=\"_blank\">Privacy Policy<\/a>.<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SEND\" \/>\n<\/p><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize alert-dismissable\" style=\"border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><\/div>\n<\/form>\n<\/div>\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"100-width.php","meta":{"footnotes":""},"class_list":["post-2324","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/pages\/2324","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/comments?post=2324"}],"version-history":[{"count":7,"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/pages\/2324\/revisions"}],"predecessor-version":[{"id":4036,"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/pages\/2324\/revisions\/4036"}],"wp:attachment":[{"href":"https:\/\/www.elcon-medical.com\/en\/wp-json\/wp\/v2\/media?parent=2324"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}