Medical Supplies & Services

Quality Defect Complaint Form

Type of report

Primary

Follow up

Name of medical Dept. contact person

Date

Primary Reporter’s Information

Name

Profession

Address

Title

Phone No*

Fax

Customers Information

Initials

Profession

Address:

Initials

Profession

Address:

Drug(s) Information

Brand

Lot

Start date

Expiry Date

Comment

Out come and possible relatedness of drug

Did the event resulted in one of the following:

Different Appearance of the drug

efected Inhaler or syringe

Open blister

Missing Leaflet

Lower quantity of the drug

Others

Details of Quality Defect “Defect Summary Description”: