1.1.1
Return Report
–
Form 001
Opr. dato:
2003-02-24
af:
EC
Rev. dato:
2003-02-24
af:
EC
Rev. nr.:
1
Company:
Address:
Phone:
Fax:
Contact person:
Date :
Following item is reported to be:
returned to INTERACOUSTICS for:
repair,
exchange,
other:
defective as described below with request of assistance
repaired locally as described below
showing general problems as described below
Item:
Type:
Quantity:
Serial No.:
Supplied by:
Included parts:
Description of problem or the performed local repair:
Returned according to agreement with:
Interacoustics,
Other :
Date :
Person :
The above mentioned item is reported to be dangerous to patient or user
1
In order to ensure instant and effective treatment of returned goods, it is important that this form is filled in and
placed together with the item.
Please note that the goods must be carefully packed, preferably in original packing, in order to avoid damage during
transport. (Packing material may be ordered from Interacoustics).
6
EC Medical Device Directive rules require immediate report to be sent, if the device by malfunction deterioration of performance or
characteristics and/or by inadequacy in labelling or instructions for use, has caused or could have caused death or serious deterioration of
health to patient or user.
Address
Drejervaenget 8
5610 Assens
Denmark
Phone
(+45) 63713555
Fax
(+45) 63713522