Type of report(s)Footnote 2
Mandatory
Voluntary
Unknown
Status of report(s)
Initial
Update
Type of shortage(s)
Anticipated medical device shortage
Actual medical device shortage
Scope of shortage(s)
National
Provincial or territorial
Unknown
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities) (required)
Description of the device: Single-use product (required)
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Medical device licence number(s) (for Class II, III and IV) (required)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s)
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act (required)
Note: Please indicate N/A for Class II, III and IV devices that have medical device licence number(s) or for Class I devices without authorization identification number(s)
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD) (required)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation (required)
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Report additional device shortages
Device 2
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 3
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 4
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 5
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 6
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 7
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 8
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 9
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Device 10
Other names (for example, trade name), if applicable
Description of the device: Package description (for example, packaging formats, sizes, quantities)
Description of the device: Single-use product
Yes
No
Class of medical device (I, II, III or IV), if known
I
II
III
IV
Unknown
Device identifier(s) (for example, catalogue number, part number, model number or unique device identifier) Footnote 4
Medical device licence number(s) (for Class II, III and IV)
Note: Please indicate N/A for Class I devices or for devices that have authorization identification number(s).
Authorization identification number(s) for Class I to IV devices authorized by Health Canada for importation or sale under another interim order made under section 30.1 of the Food and Drugs Act
Note: Please indicate N/A for devices that have medical device licence number(s) (for Class II, III and IV) or for Class I devices without authorization identification number(s).
Labelled/licensed indications (conditions or reasons for using the device) for the medical device, if known
Reason for shortage
Please select
Disruption of the manufacturing of a medical device
Device was subject to a recall
Delay in shipping of a medical device
Increase in demand for the medical device
Licensing issues (e.g. cancellation of a licence)
Export restrictions
Other
Other - Reason for shortage
Anticipated or actual start date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Anticipated or actual start date of shortage
Estimated end date of shortage (YYYY-MM-DD)
Pick a date from a calendar for field: Estimated end date of shortage
Confirmation
By checking this box the reporter acknowledges that an anticipated end date for this shortage has been provided or is confirmed as currently unknown.
Manufacturer's name (required)
Manufacturer's mailing address
Number and name of street (required)
City
Province/Territory/State
Postal code/Zip code
Country (required)