PRODUCT COMPLAINT FORM
To:
Nursing Program Coordinator - Products
Nursing Outcomes and Education
Rt. 0469
From:
_____________________________ __________ _______
Individual
Making Complaint
Extension Route
(Name and Title)
_____________________________
Department
Name
Date: _____________________________
Product/Equipment:
Manufacturer:
Product Number: Lot Number:
Designates a specific "batch
of the product.
Please attach sample of defective
material and package, when possible. If
product has been used in direct patient care, it should be placed in a sealed
container/bag and kept on the unit.
Notify Nursing Program Coordinator - Products for pick-up at ext. 20603.
Complaint:
Recommended Action:
Comments:
Nurse Manager Notified? Yes___
No___
___________________________ ___________ ________
Name of
Nurse Manager Extension
Route
10/99 P.
Townley Product Complaint Form