Product Experience Report
Section 1 - To be completed by Sales Representative, Sales Coordinator, or Document Control/Regulatory
Complaint Filled Out by
*
Complainant (Surgeon)
*
Hospital/Site
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other (Specify Below)
Date of Incident
*
-
Month
-
Day
Year
Date
Complaint
*
P/N
GTIN
Description
Lot #
Qty
Part Information
Part Information
Part Information
Part Information
Part Information
Complaint Relates to Concern About
*
Sterility
Design
Packaging
Foreign Material
Product Malfunction / Broken
Labeling
Other
Other (Specify Below)
Surgical Impact
*
Cancelled
Intervention
Procedural Delay
Patient / User Death
Patient / User Injury
None
Detailed Description of Issue
*
include date of occurrence, what happened, how it happened, the result, and whether any broken materials went unrecovered)
Detailed Description of Surgical Approach, where applicable:
*
include type and style of Surgical Approach, eg. small incision anterior
Customer Requests Follow-up
*
Yes
No
File Upload (Picture of Part)
*
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TOTAL JOINT ORTHOPEDICS
MISSION-DRIVEN™
1567 East Stratford Ave.
Salt Lake City, Utah 84106
o. 888.890.0102 f. 801.486.6117 sales@tjoinc.com
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