Complaint Entry Form

Product Complaint Report

Please complete this Product Complaint Report for any product-specific concerns or complaints you may be experiencing. When you click "Submit Report", the data will be sent directly to the Complaint Department and we will contact you shortly. If you have any questions regarding the report, please contact the Complaint Department at 1.714.427.5811 ext. 500 or toll-free at 1.800.451.3111 (US Only) (office hours Monday-Friday 9:00 am - 5:00 pm PST) or email: complaints@newportnmi.com.

Distributor Information		Remember Distributor Information?
* required
*Distributor Name:	Address:
City:	State:
* Country:	Postal Code:
*Distributor Contact:	* Email:
* Phone:	Distributor Reference Number:

Hospital/Customer Information
*Hospital/Customer:		Address:
City:		State:
* Country:		Postal Code:
* Contact Name:		* Phone:

Incident Information
* Date of Incident:	/ /
* Description of Complaint:
If problem was solved, describe steps taken:
* Settings on the equipment at the time of incident:
Complaint Type:	Specify:
* Point of Failure:	Where?
* Was there patient involvement?:	No Yes

Device Information
* Device Name/No:	* Device Serial Number:
* Part Malfunctioned:	Part Serial Number:
* Unit Equipment Hours:	Date of Last Servicing:	/ /
PM:	Overhaul:
Last Serviced By:	Telephone # of Servicing Facility:
* Software Version:	Other:

HT50 Questionnaire
Not applicable, as this is a non battery issue
* 1. Age of battery/time of interval since last replacement:
	Less than 1 year > 1 year Don't know
* 2. Did the following warnings occur:
	a. "Ext Power" warning (occurs when ventilator switches from AC to battery power) Yes No b. "Low Battery" warning (occurs prior to empty battery alarm) Yes No c. "Empty Battery" warning (occurs with 15 minute warning prior to shutdown) Yes No d. "Shutdown" alarm (occurs following ventilator shutdown) Yes No
* 3. Did alarms sound enough in advance to allow you to take appropriate actions?
	Yes No
* 4. How long was the ventilator attached to AC power prior to using battery power?
	< 5 hours >= 5 hours
* 5. How would you characterize your battery usage in terms of frequency and duration of use:
	a. Days per week 1 or less 2 3 4 5 6 7 b. Hours per day 1 or less 2 3 4 5 6 7 or more

Other Information
File Attachment (10MB limit):
If you have any comments, questions, or requests regarding the problem, please fill in the box below.

Patient Information
* Was there death or serious injury?:	No Yes If "Yes", please describe:
* What is the patient's age?:	Unknown
* What is the patient's gender?:	Male Female Unknown
* Medical Diagnosis of the patient before incident:
* Did the device alarm?:	No Yes
* If so, did the facility respond to the alarm?:	No Yes