Online Complaint & Feedback
Reporter Information
Name (name of person completing this form)
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization/Clinic/Department
*
Your Role
*
Clinician
Distributor
Research Partner
Internal Staff - QA
Internal Staff – Other
Other
Are you the individual directly involved in this complaint/feedback/inquiry?
*
Yes, I am the complainant
No, I am reporting on behalf of someone else
Name of the complainant
*
First Name
Last Name
Role of the complainant
*
Clinician
Distributor
Research Partner
Internal Staff - QA
Internal Staff – Other
Other
Product Details
Product Name / Model
*
Serial or Lot Number (if available)
Date of Use or Incident
*
-
Month
-
Day
Year
Date
Upload Image / Video (optional)
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Report Type
What would you like to report?
*
Complaint (e.g., product issue, performance concern, adverse event)
Feedback (e.g., usability suggestion, marketing comment)
Inquiry (e.g., technical or clinical question)
Complaint Description
Subject of Complaint
*
Detailed Description of the Issue
*
Was a patient involved?
*
Yes
No
How many patients were involved?
*
Was there any injury?
*
Yes
No
Describe the nature of the injury
*
Severity of the outcome
*
Minor
Moderate
Severe
Unknown
How did the issue come to your attention?
*
Actions taken so far
*
Feedback Description
Title of the Feedback
*
Detailed Description / Suggestion
*
Context of Feedback (e.g., usability, documentation, marketing)
*
Inquiry Description
Subject of Inquiry
*
Question / Details Needed
*
Have you reviewed the Instructions for Use (IFU) or User Manual?
*
Yes, I have reviewed the IFU/User Manual
No, I have not reviewed it
I couldn't find the IFU/User Manual
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