Policy Manual sample

MDT Home Health Care Agency, Inc. MEDICAL DEVICE INCIDENT REPORT FORM: Device Description: ___________________________________________________ Brand Name/Model: _________________________ Serial No. Lot: _____________ Is the Device or package available for Inspection: __ Yes __ No Company Supplier Information: __________________________________________ Contact Person: _____________________________ Phone: __________________ Have the patient report the problem to other parties: ___ Yes ___ No If yes, Provide the Name of the Company/Persons:__________________________ ___________________________________________________________________ ___________________________________________________________________ Phone: _______________________ Date of Report: _________________________ Problem Description: __________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Consequences of the Problem: __________________________________________ ___________________________________________________________________ ___________________________________________________________________ Person taking the Report: ______________________________________________ Signature: ____________________________ Date: ________________________ Home Health Agency - - Skilled Professional Services C-35