RA 3293631 – HeartSine Pad-Pak Product Defect Correction- End Customer

Medical Device Recall End User Notification Response Form

RA 3293631 – HeartSine Pad-Pak Recall
Country*
I confirm that I do possess an affected Pad-Pak batteryI confirm that I do not possess an affected Pad-Pak battery
Distributor (if known)
Which Authorised Distributor did you purchase your Pad-Pak battery from?
Serial Number Information
Please provide the lot number of your Pad-Pak(s). If your Pad-Pak(s) were supplied with a HeartSine samaritan PAD defibrillator, please provide the serial number of the defibrillator and the AED status.
Pad-Pak Replacement
You have indicated that you possess affected Pad-Pak(s). Please provide the delivery address & contact details for replacement Pad-Pak(s). This information will be shared with your Distributor who will organise any replacements.
Contact Person

First NameLast Name
Address

Street Address/Facility Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number/Contact Email
If you have further distributed any affected product, please contact Stryker Post Market at:

postmarketssp@stryker.com
Disclaimer
I acknowledge that I have received and understood the associated notification, and that all requested actions have been completed.

Any affected Pad-Pak batteries in my possession will be disposed of per local guidelines upon receiving replacement Pad-Paks. Pad-Paks distributed to my entity which are not listed above, have been used or disposed of prior to this corrective action.
Name

First NameLast Name
Business / Facility Name
Email
Phone
Signature*

Clear
If you have any questions with regards to filling in this form, please contact:

Stryker Post Market:

Email: postmarketssp@stryker.com
and Stryker will provide assistance.
Should be Empty:

Medical Device Recall End User Notification Response Form

Serial Number Information

Pad-Pak Replacement

Disclaimer