Device Complaint Handling and Vigilance Report Form
Report device complaints and vigilance incidents with essential details for prompt investigation and resolution.
Reporter Full Name
*
First Name
Last Name
Reporter Email Address
*
example@example.com
Device Name and Model
*
Device Serial or Identification Number
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Event
*
Product Complaint
Adverse Event
Near Miss
Other
Brief Description of Complaint or Incident
*
Current Status of the Device
*
Please Select
In Use
Quarantined
Returned to Manufacturer
Disposed
Unknown
Severity of the Event
*
Minor
Moderate
Serious
Critical
Actions Taken
*
Upload Supporting Evidence (photos, documents, etc.)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
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