Incident Reporting

This form is intended to help you report quickly to BII any
problem occuring with SwayStar™.
1. Was the problem related to :
Software
Hardware
Test Subject (Patient)
 
2. Please describe carefully the problem :
 
3. Did you report the problem to your local Representative ?
Yes No
 
4. Your SwayStar™ serial number is :
 
5. Your E-Mail address is :
 
6. Confirm your E-Mail address:
 
Security Code
7. Confirm security code:
 

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08.09.2014