Terumo Blood and Cell Technologies Quality Action Tool

Country *

Role *

First Name *

Last Name *

Phone *

Email *

Awareness Date *

Product Name *

Enter the product name or service if not listed above. *

Is this product available for return? *

Yes No

Terumo Blood and Cell Technologies Serial Number

Software Version

Catalog Number

Lot Number

Set Number

Back

Date of Incident *

At what point in the procedure did the incident occur? *

Please specify *

Was there a death related to this incident? *

Yes No

Was there an injury related to this incident? *

Yes No

Did this incident require medical intervention? *

Yes No

Number of Occurrences

Event Description *

Upload related materials

Add files

Back

First Name

Last Name

Phone

Back

Same as Your Information

Facility Name *

Facility Contact *

Street Address

City

State/Province/Territory

Country *

Back