Incident Questionnaire

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Case Internal Reference Number

You must be directed here by a seeded link provided by customer services.
Please contact customer services on:
Tel: 01252 344 007
Email: enquiries@welmedical.com

Incident Information

Type of Device*

Serial Number*

Date the incident occurred*

Detailed description on the incident narrative*

User facility report reference number, if applicable

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Was a patient involved?*

Was a patient involved?

Number of medical devices involved*

Who was the operator of the defibrillator at the time of incident?*

Healthcare Professional

Lay Person

Other

Has the device ever been used before in an event?*

No, this is it's first use

Yes, this device has been used in other events

In previous events, did the device operate as you would expect?

Yes

If you answered No to the above question, please give details of what happened in the previous event.

Healthcare Facility Information

Name of the healthcare facility

Contact person within the facility

Address of the facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone of contact within the facility

Email of contact within the facility

Incident/Pre Service Questionnaire Form

Incident Information

Patient Information

Healthcare Facility Information

Device Information

Faulty Device

Consumables & Accessories

Your Details

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