---
title: Medical Device Malfunction Report Form Template - FDA Compliant | Paperform
description: Report medical device malfunctions with FDA-compliant documentation. Includes patient impact assessment, device tracking, serial numbers, and automated manufacturer notification.
url: "https://paperform.co/templates/medical-device-malfunction-report"
type: static
generatedAt: "2026-03-28T00:44:28.235Z"
---

[← Back to free form templates](/templates/)    ![Medical Device Malfunction Report](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/medical-device-malfunction-report.png)
    [Preview](https://_preview.paperform.co/ai-template/medical-device-malfunction-report) [Use this template for free](/create?ai-template=medical-device-malfunction-report)    [Reporting & Incident Forms](/templates/category/reporting/)[Healthcare & Medical Forms](/templates/category/healthcare/)[Legal & Compliance Forms](/templates/category/legal/) [Healthcare](/templates/industry/healthcare/)[Medical Devices](/templates/industry/medical-devices/) [Technician](/templates/role/technician/)[Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Healthcare Administrator](/templates/role/healthcare-admin/)[Compliance Officer](/templates/role/compliance-officer/)[Risk Manager](/templates/role/risk-manager/)     About this free form template
Medical device malfunctions require immediate, accurate reporting to protect patient safety and comply with FDA regulations. Whether you're a hospital, clinic, surgical center, or healthcare professional, this **Medical Device Malfunction Report template** streamlines the entire incident documentation process—from initial discovery through manufacturer notification and regulatory submission.

Healthcare facilities face complex reporting requirements when medical devices fail or malfunction. This template captures all essential FDA reporting elements including device identification, serial numbers, lot numbers, patient impact assessments, and detailed incident descriptions. By standardizing your malfunction reporting process with Paperform, you ensure compliance while reducing administrative burden on clinical staff.

The form guides reporters through critical details: what happened, when it occurred, who was affected, and what immediate actions were taken. Conditional logic adapts the form based on severity—serious injuries or deaths trigger additional required fields for FDA MedWatch reporting, while minor malfunctions capture essential tracking data for internal quality assurance.

For risk management and quality teams, this template becomes your single source of truth for device incident tracking. Each submission includes device serial numbers, model information, manufacturer details, and photographic evidence—creating a comprehensive audit trail. You can route reports automatically to biomedical engineering, risk management, and clinical leadership based on severity level.

Connect this form to your workflow with **[Stepper](https://stepper.io)** to automate manufacturer notifications, trigger FDA MedWatch submissions for reportable events, update your incident tracking database, and alert the appropriate stakeholders immediately. No more manual email chains or lost paperwork during critical safety events.

Trusted by hospitals, surgical centers, medical device manufacturers, and healthcare compliance teams, this template ensures you capture every detail needed for regulatory compliance and patient safety improvement. Start reporting device malfunctions accurately and efficiently today.
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