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Product Name/Family -
Chief Investigator :
Investigators :
Manufacturer :
Signatures :
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Date and Version No: Insert
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1. User error
2. Procedure error
3. Product malfunction
4. Unanticipated events
Has an external clinical expert been engaged to review the new risks?
Please indicate in each event if the adverse events were due to:
1. User error
2. Procedure error
3. Product malfunction
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If yes, discuss each report in detail and provide copies of the reports, if not already
submitted to Notified Body:
Does the benefit of the product still outweigh the risk taking
Yes No
account “State of the Art” :
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Date and Version No: Insert
SECTION 4: PERFORMANCE
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