Account ID

First Name

Last Name

Work Email

Job Title

Work Phone

Company

Address

City

Country United States Canada Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Cote d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Dem. People's Rep of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Fed. States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal The Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Serbia Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine U.A.E. United Kingdom U.S.Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

State/Province Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific Armed Forces Pacific (FPO) California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code

Who was operating the device? Customer - Healthcare Professional Customer - BMET / Clinical Engineer Customer - Other Verathon - Sales / Clinical Speciallist Verathon - Internal / Other Distributor Regulatory Body Media Other

Date incident occurred

Complaint Description Please include device problem(s), details of what happened, troubleshooting, & additional information requested.

Device Type GlideScope BladderScan

Device Model

Part Number (1)

Serial / Lot Number (1)

Part Description (1)

Part Number (2)

Serial / Lot Number (2)

Part Description (2)

Part Number (3)

Serial / Lot Number (3)

Part Description (3)

When was the malfunction identified? Unknown Other Inspection Cleaning Setup Patient Procedure Unknown = Unsure when issue occurred || Other = Description listed do not fit when issue was found || Inspection = Discovered during routine preventable maintenance || Cleaning = Discovered during cleaning || Setup = Discovered before procedure took place while setting up || Patient Procedure = Problem was identified while already in-use on patient

Was there report of patient or user injury? YesNo

Was there report of patient or user death? YesNo

If identified during patient procedure did it occur during an emergency care resulting in delayed treatment? YesNo

Was there report of medical intervention due to the complaint event? YesNo

If yes, describe the intervention due to complaint

If identified during a patient procedure is information such as identifier number, age, weight, gender available? YesNo

If identified during patient procedure was a backup device used in order to complete the procedure? YesNo

Is the product being returned to Verathon? YesNo

Comments