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Template For A Field Safety Notice Customer Reply Form Customer Reply Form

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Marta
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44 views2 pages

Template For A Field Safety Notice Customer Reply Form Customer Reply Form

Uploaded by

Marta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 2

Rev 1: July 2018 LOGO/COMPANY NAME

Template for a Field Safety Notice Customer Reply Form

Customer Reply Form

1. Field Safety Notice (FSN) information


FSN Reference number* Pre-filled by manufacturer
FSN Date* Pre-filled by manufacturer
Product/ Device name* Pre-filled by manufacturer
Product Code(s) 1
2
3

Batch/Serial Number (s) 1


2
3

2. Customer Details
Account Number
Healthcare Organisation Name*
Organisation Address*
Department/Unit
Shipping address if different to above
Contact Name*
Title or Function
Telephone number*
Email*

3. Customer action undertaken on behalf of Healthcare Organisation


 I confirm receipt of the
Field Safety Notice and
Customer to complete or enter N/A

that I read and


understood its content.
 I performed all actions
requested by the FSN.
Customer to complete or enter N/A

 The information and


required actions have
Customer to complete or enter N/A

been brought to the


attention of all relevant
users and executed.
 I have returned affected
devices - enter number of
Qty: Lot/Serial Number: Date Returned (DD/MM/YY):

Qty: Lot/Serial Number: Date Returned(DD/MM/YY):


devices returned and date
complete. N/A Comments:

 I have destroyed affected


devices – enter number
Qty: Lot/Serial Number:

Qty Lot/Serial Number:


destroyed and date
complete. N/A Comments:

 No affected devices are


available for return/
Customer to complete or enter N/A

Page 1 of 2
Rev 1: July 2018 LOGO/COMPANY NAME

destruction
 Other Action (Define):

 I do not have any affected


devices.
Customer to complete or enter N/A

 I have a query please


contact me
Customer to enter contact details if different from above and brief
description of query
(e.g. need for replacement
of the product).
Print Name* Customer print name here
Signature* Customer sign here
Date*

4. Return acknowledgement to sender


Email Pre-filled by manufacturer/sender/requester
Customer Helpline Pre-filled by manufacturer/sender/requester
Postal Address Pre-filled by manufacturer/sender/requester
Web Portal Pre-filled by manufacturer/sender/requester
Fax Pre-filled by manufacturer/sender/requester
Deadline for returning the customer reply Pre-filled by manufacturer/sender/requester
form*

Mandatory fields are marked with *

It is important that your organisation takes the actions detailed in the FSN and
confirms that you have received the FSN.

Your organisation's reply is the evidence we need to monitor the progress of the
corrective actions.

Page 2 of 2

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