ACTION ITEM FORM Date: __________________________________
IMPRESSION QUALITY TO ACCOMMODATE REQUEST
To: ____________________________________
Overall poor quality impression – new impression needed Missing first bend
From: __________________________________ Left Serial #: _____________________________ Right Serial #: ____________________________ MO #: __________________________________
(Canal too short)
Missing second bend First bend too narrow Entrance of canal too narrow
CUSTOM ITE/CIC DISPENSER REQUEST
CUSTOM ITE/CIC WIDEX RECOMMENDATIONS
Family: DREAM UNIQUE
Family: DREAM UNIQUE
U-IP U-IM
Options: VC PB
H/A Model: RC VC CIC Micro Canal Half Shell 3/4 Shell Full Shell
Concha too small small to fit VC Concha too small to fit PB Helix incomplete Antitragus very prominent
H/A Model: CIC Micro CIC Mini Canal Canal Half Shell 3/4 Shell Full Shell
Venting: No Vent S M CC Vent Trench Vent VOT Vent Cutback Vent D-Vent
Design: Flex Hard Hollow Flex Hard Solid Open Hard Flex Soft Embedded Hard Modular Hard Soft Shell Extended Tip
Venting: No Vent S M Trench Vent Cutback Vent
Design: Hard 1/2 Hard 3/4 Hard Full Embedded Hard Modular Hard Soft Shell
Venting: No Vent S M Trench Vent Cutback Vent
RIC P
Thin tube: 0.9mm 1.4mm élan Tube CVT (Old)
Design: Flex Hard Hollow Flex Hard Solid Open Hard (For S&M receivers only)
Flex Soft Embedded Hard Modular Hard
RITE SP
Design: Hard 1/2 Hard 3/4 Hard Full Embedded Modular Soft Shell
Receiver: S M WIDEX RECOMMENDATIONS
Receiver: S M
Receiver: HP
U-IP U-IM
Options: VC PB Long Receiver Transverse Receiver
RIC
DISPENSER REQUEST
Receiver does not not fit in canal Canal too curved at first bend Concha too small to fit ITE circuit Concha too small to fit canal lock
P
Thin tube: 0.9mm 1.4mm élan Tube CVT (Old) Earmold
Options: Lock No Lock
RITE Receiver: HP
SP
Options: Straight Sound Bore Extended Sound Bore
SPECIAL OPTIONS 377
POSSIBLE REACTIONS OF 377
Earmold to insert RIC S Earmold to insert RIC M Can be made as 377 Originally made as 377
Protruding in CRUS VC hard to access Wire protruding in tragus Small Vent
Battery door Build up Shell pressing in tragus Canal direction off High Profile Mic direction off Battery door pressing in antitragus area
Comments: __________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ Action Needed/Diagnostic Results:________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ OE Update: __________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________
ACTION ITEM FORM Date: _______________________________
From: _______________________________
Patient Name: _________________________
Order #: _____________________________
Account #: ___________________________
MO #: _______________________________
Right Serial #: _________________________
Left Serial #: __________________________
No hearing aid in the box (Bring immediately to order entry then to CS)
H0 1 — Item entered / not found in house
Discrepancy in number of aids in box (Bring immediately to order entry then to CS)
H0 2 — Airbill signed / not in house / No AS400 Scan
UPS bag is empty/destroyed (Bring immediately to CS)
H0 4 — # of aids H CODES
SHIPPING/ORDER ENTRY INFO
To: _________________________________
REPAIR INFO
Return un-repaired Return the impression (only) to account
H0 6 — Airbill signed / scanned AS400 / not entered H0 7 — Customer discrepancy in aids(s) received H0 8 — Lost / damaged by UPS
Proceed with repair/remake
H0 9 — Shipped to incorrect account
Circuit damaged beyond repair
DIAGNOSIS
H0 5 — Airbill signed for / customer claims not rec’d.
H0 10 — Widex USA courtesy
Circuit defective (ERROR)
Wax/moisture problems
Programming issues
Battery contact problems
Shell damaged
Battery door lock broken
Battery contact corroded
Microphones defective
Receiver defective
Amplifier defective
Earwire broken/defective
Case broken
Damaged beyond repair
Unit found in good working condition
Contacts corroded
Missing or broken capacitors
Programming issues
No FB performed
Picture or note enclosed Patient name:
DIAGNOSIS
Ship-to number: Account number: Serial number not matching: Customer request: Shell color: Foreign hearing aid: Action Needed:______________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
Comments/Directions: ________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
DFM59/1217 MFF026 - REVD
__________________________________________________________________________________________________________________