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* 1. Company Name: 

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* 2.  Enter Date:

Date

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* 3. I have read and understand the recall instructions provided in the February 21st letter.

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* 4. Any adverse events associated with the recalled product?

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* 5. If yes, please explain:

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* 6. Please confirm that all affected products have been disposed of.

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* 7. Affected Product Information: Include information that is applicable for the affected product. Please attach additional sheets if necessary. 

  Product/Brand Names, UDI ( if applicable)  Manufacturer’s Product Number/Catalog Number  Lot/Serial Number shipped to Customer  Quantity in Inventory  Quantity Relabeled  Quantity Destroyed/Returned
Product 1
Product 2
Product 3
Product 4