Product Complaint Report

Please complete this Product Complaint Report for any product-specific concerns or complaints you may be experiencing. When you click "Submit Report", the data will be sent directly to the Complaint Department and we will contact you shortly.

If you have any questions regarding the report, please contact the Complaint Department at 1.714.427.5811 ext. 500 or toll-free at 1.800.451.3111 (US Only) (office hours Monday-Friday 9:00 am - 5:00 pm PST) or email: complaints@newportnmi.com.

Complainant Information
 * required Customer's Reference #:
Distributor:  Distributor Contact: 
Hospital/Customer:  Address: 
City:  State: 
* Country:  Postal Code: 
* Contact Name: * Email: 
* Phone:  Fax:
Remember Me:    

Incident Information
* Date of Incident:  / /
* Description of Complaint: 
 
Complaint:  Malfunction     Defect     Packaging     Labeling
  Other:
 
* Point of Failure: 

Testing/OVP
Setup
During Use    Where?
Other:
 
*
Was there patient involvement?:

No
Yes
 

*
Was there death or serious injury?:		 No
Yes
 
*
What is the patient's age?:  		    Unknown
 
*
What is the patient's gender?: 		Male
Female
Unknown
 
*
Medical Diagnosis of the
patient before incident:
 
*
Settings on the equipment
at the time of incident: 
 
* Did the device alarm?:  No
Yes
 
If so, did the facility respond to the alarm?:  No
Yes

Device Information
* Device Name/No: 
*
Device Serial Number: 
*
Part Malfunctioned: 		 Part Serial Number:
Unit Equipment Hours:  Date of Last Servicing:  / /
PM:  OHL: 
Last Serviced By:  Telephone # of Servicing Facility: 
SW Revision: Other:


Other Information
File Attachment:
If you have any comments, questions, or requests regarding the problem, please fill in the box below.

          

 

Copyright © 2006 Newport Medical Instruments. All rights reserved.
1620 Sunflower Ave Costa Mesa, CA 92626, USA  Tel: +1 (714) 427-5811   Toll Free: 1 (800) 451-3111   Fax: +1 (714) 427-0489
   
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