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Breas | From Hospital to Home

A global leader in Home Mechanical Ventilation, Airway Clearance and Sleep Therapy

Date of Report*
MM slash DD slash YYYY
Serial number:*
Machine type:*
If "Other" please describe:
Firmware version:
Sender contact person:*
First Last
Sender contact email:*
Company (e.g. Hospital, Caregiver, etc.):*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of purchase:
MM slash DD slash YYYY
Date of the event:*
MM slash DD slash YYYY
Description of the fault/problem (in English):*
When was the failure first detected?*
- Incoming inspection/Bench test
- During maintenance
- Prior to treatment
- During active treatment
How did the device react on the event (please check all that apply)?*
- Audible alarm
- Visible alarm
- Error code
- Alert/information on the display
- Device not possible to power up
- Alarm not expected during this event
- Visible damage on the device
Accessories used:
Are the device or log files available?*
- yes
- no
Did death or serious injury occur as a result of the event?*
- yes
- no
If yes, please provide detailed information on the patient/user injury:
Was a care-giver or qualified attendant present?*
- yes
- no
Has service been preformed according to the manual?*
- yes
- no

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Breas Medical U.S.

16 Esquire Road

N. Billerica, MA 01862

USA

Breas Medical AB/2022/ COR-SAL-MAR-000299-Rev1

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