DUKE EASY S.T.01/3AW Rev.0 01/2017
42
8.
FORM TO REPORT ACCIDENTS TO PERSONS
Dir. 93/42/EEC Annex II (G.D. 2/1 Rev. 0)
CUSTOMER NAME: ___________________________________________________________
ADDRESS __________________________________________________________________
EQUIPMENT SERIAL NUMBER __________________________________________________
DESCRIPTION OF THE ACCIDENT _______________________________________________
__________________________________________________________________________
__________________________________________________________________________
DAMAGE CAUSED TO THE PATIENT’S OR USER’S HEALTH ____________________________
__________________________________________________________________________
__________________________________________________________________________
Date ___________________________
Signature________________________
AREA RESERVED TO THE COMPANY (QUALITY ASSURANCE)
POSSIBLE CAUSES OF THE ACCIDENT:
1.
Equipment malfunctioning
2.
Deterioration of equipment features and/or performance
3.
Poor instructions for use
Other causes ________________________________________________________________
SERIOUSNESS OF THE DAMAGE ________________________________________________
__________________________________________________________________________
OPERATIVE DECISIONS PROPOSED _____________________________________________
__________________________________________________________________________
Date ___________________________
Signature________________________
AREA RESERVED TO THE COMPANY (GENERAL MANAGEMENT)
OPERATIVE DECISIONS ______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
CORRECTIVE ACTIONS _______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Date ___________________________
Signature________________________
In the event of an accident this form must be sent to O.M.S. S.p.A. with maximum urgency.