Reporting Form – SCHWERT – A. Schweickhardt GmbH & Co. KG

Incident / Near incident to get an emergency number

Fields marked with * are mandatory.

1. Administrative Information

Date of report

Classification of the incident

2. Personal details of the reporting person

First name / Last name

Contact person

Address

Postcode

Town

Country

Phone

Fax

E-Mail

3. Information on the medical device

Trade name / Product name

Model number

Catalog number

Serial number(s)

Lot Nr.

Date of purchase

Delivered by

Date of delivery

Date of first use

Date of first preparation

Number of products concerned

4. Information on the incident

Date of incident

Detailed description of the incident

Where is the medical device at the moment?

User of the medical device when incident occurred

Kind of use of the medical device

5. Patient details

Short- and long-term effects of the incident on the patient

Gender (where relevant)

Patient’s age when incident occurred

Weight in kg (where relevant)

6. Information on health facility

Name