User Feedback Form (Russia)
Feedback ID: [DDMMYY00X, “X” stands for the number of the feedback of that day]
Date: [DD-MM- YYYY]
Feedback Source: [Phone / Email / On-site / Others]
Customer Information:
Contact Person or Organization:
Contact Type: [Individuals, Healthcare professionals, Organizations]
Phone Number:
Email:
Authorized Representative
Organization Name：
Contact Person：
Phone Number:
Email:
Product Information:
Product Name:
Model:
Lot:
Serial Number:
UDI-DI:
Date of Purchase:
Problem Description:
(Please provide a detailed description of the issue, including when, where, and how it occurred.)
Problem Category:
☐ Data Anomaly
☐ Software Feature
☐ Product Structure
☐ Battery Voltage
☐ Implantation Failed
☐ Tape Detached
☐ Activation Failed
☐ Shipping & Delivery
☐ Others: [Specify]
If the issue is related to data anomalies (reading issues), kindly provide the following BGM
readings for comparison:
Time 1:
BGM Reading 1:
CGM Reading 1:
Time 2:
BGM Reading 2:
CGM Reading 2:
Photo reference on comparison (BGM)：
Does it Affect Patient or User Safety?
☐ Yes ☐ No
Attached Documents or Photos:
☐ Yes ☐ No
Please provide Documents or Photos for reference
Customer Recommendation or Expectation:
Priority
☐ Urgent
☐ High
☐ Medium
☐ Low
Internal Handling Record
Preliminary Assessment:
Responsible Department:
Investigation Lead:
Investigation Result:
(Summary of the investigation and findings.)
Status:
☐ Resolved ☐ In Progress ☐ Closed ☐ Ascend to Complaint
Approved by:
Signature:
Date: