Brand Name | HALOGEN LIGHT SOURCE |
Type of Device | HALOGEN LIGHT SOURCE |
Manufacturer (Section D) |
SHIRAKAWA OLYMPUS CO., LTD. |
3-1 okamiyama |
odakura, nishigo-mura, |
nishishirakawa-gun, fukushima 961-8 061 |
JA 961-8061 |
|
Manufacturer (Section G) |
SHIRAKAWA OLYMPUS CO., LTD. |
3-1 okamiyama |
odakura, nishigo-mura, |
nishishirakawa-gun, fukushima 961-8 061 |
JA
961-8061
|
|
Manufacturer Contact |
todd
brill
|
800 west park drive |
westborough, MA 01581
|
5082077661
|
|
MDR Report Key | 18778007 |
MDR Text Key | 336215546 |
Report Number | 3002808148-2024-01754 |
Device Sequence Number | 1 |
Product Code |
FAJ
|
Combination Product (y/n) | N |
Reporter Country Code | CH |
PMA/PMN Number | K993041 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Other,Foreign,Health Professional,User Facility,Company Representative |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
02/26/2024 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | CLK-4 |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 02/04/2024 |
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
02/19/2024
|
Initial Date FDA Received | 02/26/2024 |
Was Device Evaluated by Manufacturer? |
Yes
|
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Reuse
|
Patient Sequence Number | 1 |
Treatment | CHF-P60 |
|
|