Contract Concern

Select Form:

1. General Information

Submitted By (Name) Submitted By (Contact email) Reported by (Name) * Reported By (Contact email) *
Member Facility * Province * SSO/Health Authority *

2. Incident Information

Incident Date *
Issue Type *
Sample Product Available? *
Reported to Supplier? *
Service Area *
Incident Details *

3. Contract Information

Contract Number
Contract Name

4. Supplier and Product Information

Supplier Name * Lot Number * Product Code *
Product Expiry Date *
Product Description *

1. General Information

Name Contact Email * Contact Phone *
Member Facility * Province * SSO/Health Authority *

2. Incident Information

Incident Date *
Issue First Reported By *
Reported to Supplier/Distributor? *
Distributor Code *
Supplier or Distributor issue was reported to (n/a if not applicable) *
Urgency *
Incident Details *

3. Contract Information

Contract Number *
Contract Name *

4. Product Information

Product Number (Manufacturer) * Supplier Name Lot Number *
Product Expiry Date *
Product Description *

1. General Information

Submitted By (Name) Contact Email * Contact Phone * Facility *
Province * SSO/Health Authority *

2. Incident Information

Incident Date *
Issue First Reported By *
Reported to Supplier/Distributor? *
Supplier or Distributor issue was reported to (n/a if not applicable) *
Risk Level
Incident Details *

3. Product Information

Generic Name * Strength * Format * Lot Number *
Size * Brand Name * Manufacturer * Product Expiry Date *