Reportable incident - Kohler Medizintechnik

Report reportable incident

In case of reportable incidents, if you are unable to contact us directly, please provide us with the data below via this contact form.
We will check your message immediately.

ALL FIELDS MARKED WITH * ARE MANDATORY FIELDS.

Form Report reportable incident

Report reportable incident

1. NOTIFIER INFORMATION

First name / Surname /Company*

Contact person*

Address*

ZIP-Code, City*

Country*

Telephone*

Fax

E-mail*

2. INFORMATION ON THE MEDICAL DEVICE

Trade name / name of the product*

Item number*

Lot No.*

Purchased on*

Delivered by*

Delivered on*

First used*

Sterilised for the first time*

Number of products affected*

3. DETAILS OF THE INCIDENT

Date on which the incident occurred*

Detailed description of the incident*

Where is the medical device currently located?*

User of the medical device at the time of the incident*

Use of the medical device*

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