{"id":11854,"date":"2023-03-16T10:49:06","date_gmt":"2023-03-16T09:49:06","guid":{"rendered":"https:\/\/www.hasco-lek.pl\/incident-form\/"},"modified":"2023-05-08T13:44:42","modified_gmt":"2023-05-08T11:44:42","slug":"incident-form","status":"publish","type":"page","link":"https:\/\/www.hasco-lek.pl\/en\/incident-form\/","title":{"rendered":"Incident form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"11854\" class=\"elementor elementor-11854 elementor-11733\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-50200698 e-flex e-con-boxed e-con e-parent\" data-id=\"50200698\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4afd55ae elementor-widget elementor-widget-breadcrumbs\" data-id=\"4afd55ae\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/www.hasco-lek.pl\/en\/\">Strona g\u0142\u00f3wna<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-19d954a1 e-flex e-con-boxed e-con e-parent\" data-id=\"19d954a1\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-35bc3a27 elementor-widget elementor-widget-heading\" data-id=\"35bc3a27\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Medical incidents<br>Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-aea65d3 elementor-widget elementor-widget-spacer\" data-id=\"aea65d3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f2bb1f5 elementor-widget elementor-widget-shortcode\" data-id=\"f2bb1f5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f12732-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"12732\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/11854#wpcf7-f12732-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"12732\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f12732-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_repeaters\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_options\" value=\"\" \/>\n<\/fieldset>\n<div class=\"uacf7-form-wrapper-container uacf7-form-12732  \">\t\t<div class=\"uacf7-step uacf7-step-12732 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 1:<\/span> <span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\">Data of the person where the incident occurred<\/span>\n<br><br>\n<label>In whom did the incident occur?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-417\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-417\" value=\"at your\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">at your<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-417\" value=\"by a professional user (doctor\/medical staff)\" \/><span class=\"wpcf7-list-item-label\">by a professional user (doctor\/medical staff)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-417\" value=\"at another person\" \/><span class=\"wpcf7-list-item-label\">at another person<\/span><\/span><\/span><\/span>\n<label>Initials*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"inicjaly\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"inicjaly\" \/><\/span>\n<label>Gender*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"plec\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"plec\" value=\"Woman\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Woman<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"plec\" value=\"Man\" \/><span class=\"wpcf7-list-item-label\">Man<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"plec\" value=\"No data\" \/><span class=\"wpcf7-list-item-label\">No data<\/span><\/span><\/span><\/span>\n<label>Age<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wiek\" \/><\/span>\n<label>Body weight (kg)<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"masaciala\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"masaciala\" \/><\/span>\n<label>What part(s) of the body is involved in the incident?<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"czescciala\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"czescciala\" \/><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12732\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12732\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12732 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 2: <\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\">Information about the incident<\/span>\n<br><br>\n<label>Description of the incident*.<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Opisincydentu\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Opisincydentu\"><\/textarea><\/span>\n<label>Date of the incident<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-577\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"Data incydentu\" type=\"date\" name=\"date-577\" \/><\/span>\n<label>What were the consequences of the incident?<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-784\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-784\" value=\"Death\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Death<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-784\" value=\"Hospitalization\" \/><span class=\"wpcf7-list-item-label\">Hospitalization<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-784\" value=\"Extension of hospital stay\" \/><span class=\"wpcf7-list-item-label\">Extension of hospital stay<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-784\" value=\"Additional operation\" \/><span class=\"wpcf7-list-item-label\">Additional operation<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-784\" value=\"Doctor&#039;s visit\/additional medication\" \/><span class=\"wpcf7-list-item-label\">Doctor&#039;s visit\/additional medication<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-784\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span>\n<label>Whether the observed symptoms \/ event:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-616\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-616\" value=\"Completely gone\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Completely gone<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-616\" value=\"Persist in unchanged intensity\/form\" \/><span class=\"wpcf7-list-item-label\">Persist in unchanged intensity\/form<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-616\" value=\"There has been an improvement\" \/><span class=\"wpcf7-list-item-label\">There has been an improvement<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-616\" value=\"There has been a worsening of symptoms\" \/><span class=\"wpcf7-list-item-label\">There has been a worsening of symptoms<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-616\" value=\"No information\" \/><span class=\"wpcf7-list-item-label\">No information<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-616\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12732\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12732\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12732 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 3: <\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\">Medical device information<\/span>\n<br><br>\n<label>Name*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"nazwa\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nazwa\" \/><\/span>\n<label>Series number<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"numerserii\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"numerserii\" \/><\/span>\n<label>Medical indications (for what reason the device was used)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"wskazaniamedyczne\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wskazaniamedyczne\" \/><\/span>\n<label>Additional information about the subject of the incident, e.g. allergies, other diseases, results of additional tests related to the reported incident<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Informacjedodatkowe\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Informacjedodatkowe\"><\/textarea><\/span>\n<label>Can the product be returned to PPF Hasco-Lek S.A.?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"zwrotwyrobu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zwrotwyrobu\" \/><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12732\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12732\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12732 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 4: <\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\">Details of the reporting person<\/span>\n<br><br>\n<label>First and Last Name*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"imieinazwisko\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"imieinazwisko\" \/><\/span>\n<label>Phone number*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"numertelefonu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"numertelefonu\" \/><\/span>\n<label>Email address*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"adresemail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"adresemail\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Potwierdzeniezapoznaniasizinformacjami\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"Potwierdzeniezapoznaniasizinformacjami\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span><label>I confirm that I have read the information regarding the processing of personal data*.<br><br><strong>Information of the personal data controller<\/strong><br><br>\n\nIn accordance with Regulation (EU) 2016\/679 of the European Parliament and of the Council of 27.04.2016. on the protection of individuals with regard to the processing of personal data on the free flow of such data and the repeal of Directive 95\/46\/EC (hereinafter referred to as RODO), we would like to inform you that the Administrator of your personal data is PPF Hasco-Lek S.A., located in Wroc\u0142aw, ul. \u017bmigrodzka 242e, 51-131 Wroc\u0142aw.\n<br><br>\nYour personal data, i.e. Name, surname, address, telephone number, e-mail address, health data will be processed for purposes:\n<br><br>\nEnsure high standards of quality and safety of medicinal products and, in particular, monitor the safety of medicinal products, including keeping a register of reports of individual cases of adverse reactions to medicinal products and reporting individual cases of adverse reactions to medicinal products to the competent authorities:\n- health data will be processed on the basis of Art. 9 paragraph. 2(i) RODO, i.e.. processing is necessary for reasons of public interest in the field of public health in the form of ensuring high standards of quality and safety of medicinal products on the basis of a legal provision, i.e. based on art. 36e para. 1 of the Pharmaceutical Law;\n- other personal data will be processed on the basis of Art. 6 sec. 1(c) RODO, i.e.. processing is necessary for the fulfillment of the Administrator's legal obligation under Art. 36e para. 1 of the Pharmaceutical Law;\nto contact the treating physician and obtain additional information in connection with adverse reactions to the medicinal product from the treating physician - on the basis under Art. 6 sec. 1(c) RODO, i.e.. processing is necessary for the fulfillment of the Administrator's legal obligation under the law. Art. 36e para. 1 of the Pharmaceutical Law;\nTo establish, assert or defend possible claims between you and the Administrator - with regard to health data on the basis of Art. 9 paragraph. 2(a) of the RODO, i.e. processing is necessary for the establishment, investigation or defense of claims; for other ordinary data under Art. 6 sec. 1(f) RODO, i.e.. on the basis of the legitimate interest pursued by the Administrator, which is the possibility of pursuing claims.\nNo decisions will be made against you by automated means, including following profiling.\n<br><br>\nProvision of data is voluntary. Your personal data may be disclosed to the following entities: Your attending physician (if you consent to be contacted by your attending physician), IT service providers, entities providing consulting, legal services; also to entities and authorities authorized to process such data under the law, in particular the President of the Office of Medicinal Products, Medical Devices and Biocidal Products, the European Medicines Agency and other competent authorities of the European Union member states where the Administrator has obtained marketing authorization for a medicinal product.\n<br><br>\nPersonal data will be processed for the period necessary for the purposes for which the data are processed or until an objection is raised (if the basis of processing is the legitimate interest of the Administrator) or until consent is withdrawn (if the basis of processing is the consent granted) - whichever occurs first. After the above period, personal data will be kept for a period of 10 years from the expiration date of the batch of medicinal product for which the application was submitted or until the statute of limitations for claims.\n<br><br>\nYou have the following rights: the right to object, to access the content of your personal data, to correct, delete them (the so-called \"Right to be forgotten\"), the right to limit processing, the right to their portability as well as the right to lodge a complaint to the supervisory authority - the President of the Data Protection Authority, (web address: https:\/\/uodo.gov.pl\/pl\/p\/kontakt ), if you consider that our processing of your personal data is in violation of the law.<\/label>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Wy\u015blij\" \/><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Medical incidentsForm<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-11854","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - 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