FSN18001
ANNEX B RECEIPT CONFIRMATION (USER)
Ref. to FSN 18001
Ref. to FSCA 18001
Product Code: CAR POLE
From our data, you should have received a device affected by this Field Safety Corrective Action.
We kindly asked you to return via fax (at the number 041/5937011) or email at
This
page – filled and signed for acceptance – as soon as possible.
User information
Hospital name
Hospital address:
System serial number(s):
Field Safety Notice Receipt confirmation
□ I have received the updated instructions for use
□ I will use the system according to the updated instructions
OR
□ In the hospital there are no more systems affected by this corrective action
□ Transferred to
□ Decommissioned
For acknowledgement
(name of the responsible person)
(role)
(signature)
(date)
( contact mail/ phone)
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