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Regulatory Notices
Vicon MX Hardware System Reference E-3
MHRA Adverse Incident Report Form
Please tick (9) the appropriate boxes
* indicates that an entry is required in order to submit the form.
Origin of Report
*Type of “Injury” (tick one only)
Type of device (tick one only)
* Reporting Organisation
(give details)
* Address
* Reporter’s Name
Position/Occupation
Telephone Number
E-Mail
This address will be used to send you a copy of
the completed form if completed online
(separate multiple addresses with a comma).
Laboratory (if relevant)
Prosthetic & Technician Co
(if relevant)
Local Reference Number
Consultant in Charge
(if known)
This report confirms a
Telephone report Fax report Neither
Fatality Serious Revision Distress Minor None
Other (please specify)
Further details can be given on additional
sheets if necessary.
MXhardware_Reference.book Page 3 Monday, April 30, 2007 1:56 PM
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