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Customer Complaint Form
* Required information
Date of Submission:          Thursday, July 31, 2014         
A: CUSTOMER INFORMATION
Blank * Company Name:
Blank Address:
* Street:  
Street (cont):
* City:  
* State/Province:
* Zip:
Blank * Contact Name:
* Phone:
Fax:
* E-mail:
Blank Report/Complaint#:
B: BACKGROUND INFORMATION
Blank * Describe Exact Details of Problem/Defect:
 
Blank* Types of Actions Requested:
Notification and No Response Needed
Investigation
CAPA (Corrective Action Plan)
Credit
Return
Other
Blank * Where Detected:
Incoming
Post Processing
After Assembly
Field Complaint
Other
 
Blank * Processing by Your Company:
Washed Only
Washed and Sterilized
Sterilized Only
None - Used as Received
 
 
If Sterilized, Type: ETO Steam Gamma Other
Blank Siliconized?:
Blank Describe Exact Details of Processing (Times, Temperatures, etc.):
C: INSPECTION DETAILS
Blank
 
Specification # on File:
Defect Out of Specification:
Accept/Reject (AQL):
# Inspected:
* # Detected:
* Incident Rate %:
 
Utilized Inspection Standard: Other:
 
QA/Manufacturing contact who can provide more details on defect:
* Name:  * Phone:
Email:   
 
 
D:SUSPECT PRODUCT
Customer and West details being requested can be located on shipping and product labels that are placed on every carton. If carton labels are not available, the details can also be obtained from our Certificates of Conformance.
 
 
Blank SKU #:
Example Label
Blank
Blank* PO #:
Quantity Received:
Quantity Rejected:
(if applicable)
Blank * West Order #:
Blank * Master Lot #:
 
 
 
 
 
 
 
If Field Complaint:
What is the Product Name:
 
Blank * West Detail Item:
Example Label:
Blank
Blank Formulation:
Blank West Sub Lot(s):
Blank Carton #:
Blank Item Description:
 
 
 
 
 
 
Other Product Details/Comments:
 
E: SAMPLE INFORMATION
Blank Are defects samples available for evaluation?:
*If Yes, please provide samples to West.
# of Samples Submitted With Defect:
# of Samples Submitted Without Defect (Control):
 
Provide Control Lot #:
 
Have samples been in drug contact? 
 
West Sales Representative:
West Account Services Representative: