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FHIT TEC_FHIT_M Rev.1 11/2016
36
8. PEO
PLE’S INJURY ADVISORY
Dir. 93/42/CEE All. II (D.G. 2/1 Rev. 0)
CUSTOMER NAME ____________________________________________________________________
ADDRESS ___________________________________________________________________________
N° SERIAL NUMBER __________________________________________________________________
INJURY DESCRIPTION ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
DAMAGE HEALTH OF THE PATIENT OR THE USER ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date _______________________________
Sign _______________________________
SPACE RESERVED FOR THE COMPANY (QUALITY INSURANCE)
POSSIBLE CAUSES OF INJURY:
Disfunction
Characteristics and/or performance deterioration
Instruction for use deficiency
Other _______________________________________________________________________________
DAMAGE GRAVITY ___________________________________________________________________
____________________________________________________________________________________
OPERATIVE DECISION PROPOSED _____________________________________________________
____________________________________________________________________________________
Date _______________________________
Sign _______________________________
RESERVED COMPANY SPACE (GENERAL DIRECTION)
OPERATIVE DECISION ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
CORRECTIVE ACTION _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date _______________________________
Sign _______________________________
In case of injury send this form to BEON SOLUTIONS SRL AS SOON AS POSSIBILE
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