BEUDAMED
    FDA Adverse Event Other Summary report: N

    SERIES 107 POWER WHEELCHAIR

    MDR report key: 555001 · Received November 15, 2004

    Report

    Report Number
    3004620958-2004-00001
    Event Type
    Other
    Date Received
    November 15, 2004
    Date of Event
    July 1, 2002
    Report Date
    November 15, 2004
    Manufacturer
    CHIEF POWER CHAIR, LLC
    Product Code
    ITI
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    INVALID DATA

    Narratives

    Description of Event or Problem · 1

    THIS FORM COMPLETED IN 11/15/04 TO REPLACE FDA 3500 SUBMITTED ON 9/04.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 SERIES 107 POWER WHEELCHAIR POWER WHEELCHAIR ITI CHIEF POWER CHAIR, LLC * *

    Patients

    Seq Age Sex Outcome Treatment
    1 UNKNOWN Other