Product Experience Report

Submit a Report

This form is used to submit a summary of a reported incident.

"*" indicates required fields

Email Address*

Enter the email address to receive a copy of this form submission for your records.

Contact Information

Hospital Name*

Hospital Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hospital Contact Name*

First Last

Hospital Contact Title*

Hospital Contact Phone*

Hospital Contact Email*

Agent Information

Agency Name*

Agent Phone*

Agent Email*

Product Information

Product Description*

Catalog #*

Serial / Lot #*

Quantity*

Is the product(s) available for return?*

If no, please provide a reason

Event Information

Date of Event*

When did the event occur?*

If other, please provide information

Event Description*

Please provide a detailed description of the event. Be sure to include the who, what, when, and how for the event.

Photo of Affected Product

Max. file size: 5 MB.

Patient Impact Assessment

Is the reported event associated with the Stubmed Toga?*

Did the reported event lead to a surgical delay / prolongation?*

Patient Information (FDA / FUMDR Required)

Patient Age*

If known, Patient Date of Birth

Patient Weight*

Patient Gender*

Patient Medical History*

What was the following outcome for the patient surgery following the event?*

Additional Comments

Additional File Upload

Max. file size: 5 MB.

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Phone

This field is for validation purposes and should be left unchanged.