Field Safety Notice Confirmation Form - Smiths Medical

ATTACHMENT 1 Smiths Medical ASD, Inc.
URGENT MEDICAL FIELD SAFETY NOTICE
CONFIRMATION FORM
for Graseby MR10 Neonatal Respiration Monitor
Please complete and return this Form by Fax to +44 (0) 1582 430001 or by sending an electronic copy via
email to MR10BatteryStraps@smiths-medical.com
Check all applicable boxes below:
Printed
Name:
Signature:
Facility
Name:
YES - I have Graseby MR10 Neonatal Respiration Monitor (MR10)
with one or more of the following;
- Serial Numbers on the attached list (attachment 2),
- Battery Strap spares purchased between1 November 2010 and 14
October 2011;
- Units that have had Battery Straps replaced at Smiths Medical Service
and Repair between 1 November 2010 and 14 October 2011
Please send me replacement Battery straps (which include the instructions),
so we can proceed with making the Battery Strap replacement.
Enter total number of
affected MR10s:
_______
Please enter Serial Numbers on page 2
YES - I have Graseby MR10 Neonatal Respiration Monitors with one or Enter total number of
more of the following;
affected MR10s:
- Serial Numbers on the attached list (attachment 2),
_______
- Battery Strap spares purchased between1 November 2010 and 14
October 2011;
- Units that have had Battery Straps replaced at Smiths Medical Service
and Repair between 1 November 2010 and 14 October 2011
Please contact me at the phone number or email listed below. Smiths
Medical will contact you as soon as possible with instructions for returning
your affected MR10 for the correction.
NO - I do not have any Graseby MR10 Neonatal Respiration Monitors with one or more of the
following;
- With Serial Numbers on the attached list (attachment 2).
- Battery Strap spares purchased between1 November 2010 and 14 October 2011;
- Units that have had Battery Straps replaced at Smiths Medical Service and Repair between 1
November 2010 and 14 October 2011
I no longer have any Graseby MR10 Neonatal
Respiration Monitors. The MR10s have been
transferred to the following location:
I have indicated all of the Graseby MR10 Neonatal Respiration Monitors on Attachment 2 that are
no longer in service and have been made inoperable and disposed of.
Department:
Date:
Facility
Address:
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30-November-2011
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Phone
Number:
Shipping
Address:
( ) - Ext: Email:
Please List Your Monitors Serial Number if Applicable
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