Brand Name | COVID-19 AT-HOME TEST |
Type of Device | CORONAVIRUS ANTIGEN DETECTION TEST SYSTEM |
Manufacturer (Section D) |
SD BIOSENSOR, INC. |
c-4th&5th,16, deogyeong-daero |
1556beon-gil, yeongtong-gu |
suwon-si, gyeonggi-do 16690 |
KS 16690 |
|
Manufacturer (Section G) |
SD BIOSENSOR, INC. |
c-4th&5th,16, deogyeong-daero |
1556beon-gil, yeongtong-gu |
suwon-si, gyeonggi-do 16690 |
KS
16690
|
|
Manufacturer Contact |
amy
nelson
|
9115 hague road |
na |
indianapolis, IN 46250
|
3174767531
|
|
MDR Report Key | 15625583 |
MDR Text Key | 307160128 |
Report Number | 1823260-2022-03229 |
Device Sequence Number | 1 |
Product Code |
QKP
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | EUA210661 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Consumer |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
10/18/2022 |
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 |
Lay User/Patient
|
Device Expiration Date | 09/21/2022 |
Device Catalogue Number | 09666672160 |
Device Lot Number | 53K33W1T11 |
Was Device Available for Evaluation? |
No
|
Initial Date Manufacturer Received |
09/21/2022 |
Initial Date FDA Received | 10/18/2022 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Patient Sequence Number | 1 |
Treatment | AMLODIPINE.; ATORVASTATIN.; LEVOTHYROXINE.; OZEMPIC 0.5MG INJECTION SHOT.; PROTONICS.; TRAZODONE.; XANAX 1MG AT BEDTIME. |
Patient Age | 69 YR |
Patient Sex | Female |
Patient Weight | 75 KG |
|
|