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FCI Complaint Form 112019 docx 2026
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- Click ‘Get Form’ to open the FCI Complaint Form 112019 in the editor.
- Begin by filling out the 'Customer Information' section. Enter the facility name, surgeon's name, and complete address details including state, city, and zip code.
- Provide contact information by entering the contact person's name, phone number, account number, and email address.
- In the 'Date of Procedure' field, specify when the procedure took place. Then describe the incident in detail, noting when it occurred relative to surgery and any other devices used.
- Indicate if there was a patient impact by selecting 'YES' or 'NO'. If applicable, explain how the patient was impacted and treated.
- Fill in product details such as item number, description, lot/serial number, and expiration date. Attach a photo of the product if required.
- Ensure you provide proof of decontamination for products that had patient contact before returning them.
- Finally, sign and date the form to confirm that all information is complete and accurate.
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