Compliant Form Review Page

Product Complaint Reporting Form

Product complaints may be submitted completing the online form or by submitting a complaint via mail or via our online form:

Mail Complaint

Submit Complaint Online

Privacy Notice for Complaint Handling

ApiJect Systems Corp.
Attn: Complaint Management Center
2 High Ridge Park, Suite 2,
Stamford, CT 06905

If submitted via mail, ensure the following information is included:

Date of Report
Date of Event Occurrence
Reporter Name
Product Number
Lot/Batch Number
Detail Description of Event/Complaint
Request for follow up
If samples are available to request, including photos
Harm or injuries sustained
Patient Demographic Information (I.E. Gender, race, age, weight, ethnicity)

* Do not include confidential patient health information when submitting a product complaint.

Company Name(Required)

Contact(Required)

Limit 80 characters

First Name (required) Last Name (required)

Contact Location(Required)

Street Address (required) Street Address 2 (required) City (required) State / Province / Region (required) ZIP / Postal Code (required) Country (required)

Email(Required)

Phone(Required)

Date of Event Occurrence(Required)

Source of Complaint

Reporter Contact Information

Product Information

Product Name(Required)

Manufacturer Date(Required)

Product Number(Required)

Lot/Batch Number(Required)

Expiration Date(Required)

UDI Number

Quantity(Required)

Detailed Description of Event/Complaint †(Required)

Were there any injuries sustained/harm? † Please do not include confidential patient health information when submitting a product complaint.

Where was the problem detected(Required)

Request for Follow-up?(Required)

Are samples available to Request?(Required)

Type of samples available(Required)

Are samples decontaminated?(Required)

Patient Demographic Information

Date Of Birth

Date of Birth(Required)

Sex Assigned at Birth(Required)

Gender(Required)

Gender Other

Gender Other Selected, Please Detail.

Weight in Pounds(Required)

Height in Inches(Required)

Race(Required)

Ethnicity(Required)

Relevant Concomitant Conditions, incl. pregnancy(Required)

Any additional information relevant to the incident?(Required)

Was there any impact to a patient or HCP or User or Other?(Required)

Who was impacted?(Required)

Was the user exposed to hazardous/blood/bodily fluids?(Required)

Was the patient treatment altered because of this malfunction?(Required)

Upload any attachments

Max. file size: 50 MB.

* Please do not include confidential patient health information when submitting a product complaint.