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DEVICEVUE ASSET TRACKING

INFUSION DASHBOARD

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Single set technology

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doseedge workflow manager

infusion analytics

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Return Authorization Form

*indicates required field

Facility Name*

First Name*

Last Name*

Phone Number*

E-mail*

Serial Number or Mac Address*

Description of event or issue*

Upload a PO*

Did this event occur during Therapy, Diagnosis, or biomed testing?*
Therapy Diagnosis biomed testing Unknown

Please describe*

Was there any patient involvement?*
Yes No

Did this event occur prior to putting this device into service at your facility?*
Yes No Unknown

Please describe the circumstances (e.g. particular step of the pump operating process, any applicable pump testing data) in which this event occurred, enter UNKNOWN if this information is not available*

Event occurrence date for the issue (if known)?

What was the care area this event occurred in?*
Unknown
BioMedical Service
ICU
NICU
ER
Pediatrics
Med/Surg
Other

If necessary, is there anyone else who may be contacted for additional information related to this event? Please provide their contact information below:

Unknown

Name

Title

Phone Number

What is the Status of the device?*
Device will be returned to Baxter Medina
Other

Spectrum IQ infusion system is Rx Only

For the safe and proper use of the devices referenced within, refer to the complete Instructions for Use or the appropriate manual. Please refer to manufacturer’s Package Insert for drug products mentioned herein for Full Prescribing Information.

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