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First Name
Last Name
Email
Phone fix or mobile
Date of Birth
Country of Residence
Select Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo (Kinshasa)
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo (Brazzaville)
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
United States (US) Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Have you been using one of the recalled products?
Yes
No
Please select the model from the list
- Select -
E30 (Emergency Use Authorisation)
DreamStation ASV, DreamStation BiPAP autoSV
System One ASV4, System One BiPAP auto SV, System One BiPAP auto SV Advanced
OmniLab Advanced PlusSleep Lab Titration Devices
BiPAP ASV II & III Legacy BiPAP
DreamStation ST, AVAPS, DreamStation BiPAP AVAPS, DreamStation BiPAP S/T
S/T C Series, AVAPS, System One BiPAP AVAPS(C Series), System One BiPAP S/T (CSeries)
BiPAP Synchrony IILegacy BiPAP
System One 50 series CPAPs, Auto CPAP, BiPAPs
DreamStation CPAP, Auto CPAP, BiPAP
Dorma 400, 500 CPAP, Auto CPAP, BiPAP ASV II & III Legacy BiPAP
System One 60 series, CPAPs, Auto CPAP, BiPAPs
DreamStation GO CPAP, APAP, Auto CPAP
Trilogy 100 Ventilator
Trilogy 200 Ventilator
Garbin Plus, Aeris, LifeVent Ventilator
A-Series BiPAP Hybrid A30, BiPAP Hybrid A30Ventilator (A-Series)
A-Series BiPAP V30 Auto Ventilator, BiPAP V30 Auto
A-Series BiPAP A40, BiPAP A40 Ventilator (A-Series)
A-Series BiPAP A30, BiPAP A30 Ventilator (A-Series)
Other/I do not know
Year of first use
- Select -
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Year of last use
- Select -
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
currently using the device
Do you have the memory card (SD or microSD or other) of your medical device or have you saved a backup?
Yes
No
In case of mechanical ventilators (no sleep apnea devices): have you ever been prescribed the use of one of such breathing devices at home or at a medical facility?
Yes
No
If yes, can you indicate where and in what period?
Mechanical Ventilator model
- Select -
Trilogy 100 Ventilator
Trilogy 200 Ventilator
Garbin Plus, Aeris, LifeVent Ventilator
I do not know
In case you do not know the model, can you contact the healthcare facility and ask them to provide you with brand and model?
Yes
No
Are you suffering from a medical condition, illness, or injury that might have been cause by the use of the recalled devices?
Yes
No
If you answered Yes above please select below:
Nasal Cavity Tumor
Lung Tumor
Thyroid Tumor
Laryngeal Tumor
Esophageal Tumor
Oropharyngeal Tumor
Acute Myeloid Leukemia
Chronic Myeloid Leukemia
Asthma
Asthma Exacerbation
Chronic Bronchitis
Exacerbation of Chronic Bronchitis
Pneumonia
Pulmonary Emphysema
Chronic Obstructive Pulmonary Disease
Other
Have you ever received a recall letter regarding any such devices?
Yes
No
If yes, select year and month
- Select -
2021
2022
2023
2024
Month (e.g. 5 = May)
- Select -
1
2
3
4
5
6
7
8
9
10
11
12
Are you a relative (e.g. mother/father, bother/sister) to a person that has been using a recalled product?
Yes
No
I have read and agree to the
Privacy&Coockie Policy
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