APOC Customer Contact Form

Your Information

Name*

Email*

Employer*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Do you have any customer enquiries, complaints, or repairs this month?*

Yes

No

Select Month and year for “no customer contacts” reported.

General Information

Incident No.

Date of Customer Contact*

Reason For Registration Delay*

Date Entered In Business Partner Complaint System*

Date Closed In Business Partner Complaint System

Customer Information

Customer Disclosure

I am not allowed to disclose this information

Customer Name*

Customer Email*

Customer Employer*

Customer Address*

Customer Address 2*

Customer Town / City*

Customer State / Province / Territory*

Customer Country*

Customer Zip (Postal) Code

Customer Phone*

Customer Fax

Number

Product Information

No. of Product Issues

Product 1

Product 1: Name*

Product 1: Language

Product 1: Information*

Part / List No.

Lot / Serial No.

CLEW version

Analyser version

Unit Set

Data mgmt version

Request a Return

RGA No.

Chargeable PO No.

Quantity

Product 2

Product 2: Name*

Product 2: Language

Product 2: Information*

Part / List No.

Lot / Serial No.

CLEW version

Analyser version

Unit Set

Data mgmt version

Request a Return

RGA No.

Chargeable PO No.

Quantity

Product 3

Product 3: Name*

Product 3: Language

Product 3: Information*

Part / List No.

Lot / Serial No.

CLEW version

Analyser version

Unit Set

Data mgmt version

Request a Return

RGA No.

Chargeable PO No.

Quantity

Product 4

Product 4: Name*

Product 4: Language

Product 4: Information*

Part / List No.

Lot / Serial No.

CLEW version

Analyser version

Unit Set

Data mgmt version

Request a Return

RGA No.

Chargeable PO No.

Quantity

Product 5

Product 5: Name*

Product 5: Language

Product 5: Information*

Part / List No.

Lot / Serial No.

CLEW version

Analyser version

Unit Set

Data mgmt version

Request a Return

RGA No.

Chargeable PO No.

Quantity

Incident Description

Provide a clear concise problem statement describing the customer's enquiry, complaint, or repair. Refer to Q04.01.007. section 2.4, or Q04.01.001 as appropriate, for a detailed list of meaningful data to collect. The problem statement should address the following questions:

What is happening with the system, the assay or the analyser?
What is not happening that should be?
Where is the issue being seen?
Where is there no issue in the system (or what assays or tests, etc. are performing without issues)?
When is the issue occurring?
When is the issue NOT manifesting itself?
How extensive is the issue (or how limited)?
Is there specific data applicable to the situation?
What were the expected results? Do the results fit the clinical picture?

Incident Description

Support Summary

Associated documents used to provide guidance, troubleshoot or resolve the customer issue/concern, must be referenced.

Include troubleshooting steps provided to customer

Asked customer to perform ceramic cartridge
Assisted customer with software update procedure

Include if i-STAT equipment will be repaired or replaced.

Summary

Resolution

Was The Issue Resolved Through Your Troubleshooting Steps?*

Yes

No

I don't know

If no, please provide additional steps to be taken, if any.

Review

Customer contact reports will be sent to Abbott Point of Care Technical Services by the 15th of the following month.

{all_fields}

List

Name

This field is for validation purposes and should be left unchanged.

Your Information

General Information

Customer Information

Product Information

Product 1

Product 2

Product 3

Product 4

Product 5

Incident Description

Support Summary

Incident Review

Adverse Event Evaluation Questions

Incident Report

Resolution

Review

Customer contact reports will be sent to Abbott Point of Care Technical Services by the 15th of the following month.