PRODUCT COMPLAINT FORM
Nursing Program Coordinator - Products
Nursing Outcomes and Education
From: _____________________________ __________ _______
Individual Making Complaint Extension Route
(Name and Title)
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.
Nurse Manager Notified? Yes___ No___
___________________________ ___________ ________
Name of Nurse Manager Extension Route
10/99 P. Townley Product Complaint Form