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Earmold to insert RIC S Earmold to insert RIC M Can be made as 377 Originally made as 377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: __________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________