Study Title: IRB #: Principal Investigator: Sponsor: Study Site: Device Name: DEVICE RECEIPT DEVICE USE DEVICE RETURN / REPAIR / DESTRUCTION RET= Returned Initials Lot # / Device Type / Date DES= of Subject Date Date # of Reason Comments Serial or Initials Units ID Rec’d Batch # Used Destroyed Device Model # REP= Dispenser Repaired Note: Retain a copy of the packing slips for all shipments received and sent.
Study Title: IRB #: Principal Investigator: Sponsor: Study Site: Device Name: DEVICE RECEIPT DEVICE USE DEVICE RETURN / REPAIR / DESTRUCTION Date Rec’d Lot # / Serial or Model # Device Type / Batch # Date Used Initials of Device Dispenser Subject ID RET= Returned DES= Destroyed REP= Repaired Date Initials # of Units Reason Comments Note: Retain a copy of the packing slips for all shipments received and sent.
device_accountability_log.docx