Company/Customer Complaint Reference # Company/Customer Complaint Reference #
* Customer Item/Product # *Customer Item/Product #
West Item/Product # West Item/Product #
West Item/Product Description Weat Item/Product Description
* Description of Problem *Description of Problem
* Event Date *Event Date
* Awareness Date *Awareness Date
* Where was the problem detected *Where was the problem detected
Has there been any additional processing by your company (i.e washed, sterilized etc.)? Has there been any additional processing by your company (i.e washed, sterilized etc.)?
* West Location purchased from *West Location purchased from
Please Select
West - North America
West - Brazil
West - Europe
West - Asia Pacific
MediMop
Contract Manufacturing - Phoenix Arizona
Contract Manufacturing - Tempe East Arizona
Contract Manufacturing - Tempe West Arizona
Contract Manufacturing - Indiana
Contract Manufacturing - Michigan
Contract Manufacturing - Pennsylvania
Contract Manufacturing - Puerto Rico
Contract Manufacturing - France
Contract Manufacturing - Dublin
Lot / Batch #'s impacted. Document when known. If unknown, indicate unknown. Lot / Batch #'s impacted. Document when known. If unknown, indicate unknown.
Delivery Number Delivery Number
Purchase Order (PO) Number Purchase Order (PO) Number
Serial #'s impacted. Document when known. If unknown, indicate unknown. Serial #'s impacted. Document when known. If unknown, indicate unknown.
Are samples available for evaluation? Are samples available for evaluation?
Please Select
Yes
No
If yes, please provide shipping carrier name (I.e. FedEx, UPS etc) If yes, please provide shipping carrier name (I.e. FedEx, UPS etc)
If yes, please provide tracking information If yes, please provide tracking information
West Order Fulfillment Representative West Order Fulfillment Representative
West Account Manger West Account Manager