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HealthTech Ghana Limited Support Centre
Medical Devices & Consumables Online Issues and complaint Reporting Form
Fill Your information
Your Hospital/Clinic Name
Date of Report
Your Department with in the Hospital or Clinic
Full Name
Email
Phone
Your Job Role:
Product Brand
B.Braun
Philips-healthcare
Flexicare
Abbott
Merit Medical
Mindray
Baxter
Henry Schien
Kyoto Kugaku
Tuttnauer
Intra special catheters
Dr. Japan
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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Critical Care & Intensice Care
Cardiology & Cath-Lab
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Emergency & Trauma
Hospital CSSD
Medical Training
Internal Medicine
Oncology & Haematology
Public Health & Preventive Health
Diagnostic Imaging
General Surgery
Medical Devices & Equipment
Medical Consumables
Hospital Furniture
Pharmaceuticals
Healthcare Project
Support
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