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