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Medical Devices & Consumables Online Issues and complaint Reporting Form

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Your Hospital/Clinic Name

Date of Report

Your Department with in the Hospital or Clinic

Full Name

Phone

Your Job Role:

Product Brand

Product Model

Device Name

Model/Serial Number

Location of Device

Batch Number (if is a consumable)

Description of Fault or Defect

Details of any Adverse Events or Injuries (if applicable)

Remedial Actions Taken

Immediate Actions Taken (if any)

Was the Device in Use at the Time of the Fault?

Yes No

Was the Device Being Used According to Manufacturer's Instructions?

Yes No

Has the Fault been Reproduced or Verified?

Yes No

Any Attempts at Troubleshooting or Corrective Measures?:

Yes No

Any Previous Faults or Repairs on this Device?

Yes No

Any Similar Faults Reported by Others?

Yes No

Attach any relevant photos, videos, or documents related to the fault

Declaration

I, hereby declare that the information provided in this fault report is accurate and complete to the best of my knowledge. I understand that any false information may impact the investigation process.

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Manchester Club House, 140-144, 7th Street, New Bortianor, The West Hills, Accra, Ghana
P.O.Box TI 581, Taifa, Accra, Ghana
Digital Address: GS-030-3005
+233 240 308 902
office@healthtechghana.com

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