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Submission: On March 28 via manual from US — Scanned from DE
Submission: On March 28 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /se/705E3ED85708C4B5
<form class="form-horizontal" role="form" action="/se/705E3ED85708C4B5" method="post" enctype="multipart/form-data" onsubmit="return ProcessPage();" novalidate="">
<script>
document.documentElement.className += " js";
</script>
<section class="header-wrapper">
<div class="p-logo-wrapper">
<div class="p-logo">
<a title="" target="_top" class="p-refresh"></a>
<span class="p-workmark-title p-default">Survey</span>
</div>
</div>
</section>
<div class="container-fluid page-content">
<div class="row">
<div class="col-md-10 col-md-offset-1">
<p class="text-block" id="T1" tabindex="0"><span face="Verdana" font-size="16px" style="font-size: 16px; font-family: Verdana;"><img src="/surveys/1885224664/5708c4b5/img001.png?D8E86DA7" style="height: 141px; width: 250px;"><br><br>You
should have recently received a letter and/or a postcard informing you a problem has been identified in the Philips M5071A (adult) and M5072A (infant/child) AED pads that could pose a risk for patients or users. <span
style="font-size: 12pt; font-family: Verdana;">Unexpired M5071A Adult pads cartridges with a LOT number beginning with “Y” will be replaced, free-of-charge.<br><br>To learn more about the SMART Pads Medical Device Correction, visit
<a href="http://www.philips.com/pads-notice">www.philips.com/pads-notice</a>.</span><br style="background-color: rgb(217, 235, 255); margin: 0px; padding: 0px; font-size: 16px; font-family: Verdana;"><br
style="background-color: rgb(217, 235, 255); margin: 0px; padding: 0px; font-size: 16px; font-family: Verdana;">In order to do this, we need you to verify some information about you and your AED(s). Key information fields are marked
with an asterisk (<span color="#ff0000" style="color: rgb(255, 0, 0);">*</span>) please provide the information to the best of your ability.</span></p>
<h1 id="S1" class="section-heading"> Tell us about yourself </h1><!--Q2_START-->
<fieldset id="Q2_WRAPPER" class="question shortanswer">
<legend id="Q2_LEGEND" class="sr-only">
<label for="Q2_1"></label>
</legend><span id="Q2_QUESTION_TEXT"><a id="Q2_HEADING" class="question-heading anchor"></a><label for="Q2_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Name <span color="#ff0000"
style="color: rgb(255, 0, 0);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q2_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q2_1" id="Q2_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q2_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 3 before continuing. </div>
</fieldset><!--Q2_END-->
<!--Q3_START-->
<fieldset id="Q3_WRAPPER" class="question shortanswer">
<legend id="Q3_LEGEND" class="sr-only">
<label for="Q3_1"></label>
</legend><span id="Q3_QUESTION_TEXT"><a id="Q3_HEADING" class="question-heading anchor"></a><label for="Q3_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Organization/Company (if
applicable)</span></label></span>
<div class="response-set" aria-labelledby="Q3_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q3_1" id="Q3_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
</fieldset><!--Q3_END-->
<!--Q4_START-->
<fieldset id="Q4_WRAPPER" class="question shortanswer">
<legend id="Q4_LEGEND" class="sr-only">
<label for="Q4_1"></label>
</legend><span id="Q4_QUESTION_TEXT"><a id="Q4_HEADING" class="question-heading anchor"></a><label for="Q4_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Street address <span color="#ff0000"
style="color: rgb(255, 0, 0);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q4_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q4_1" id="Q4_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q4_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 5 before continuing. </div>
</fieldset><!--Q4_END-->
<!--Q5_START-->
<fieldset id="Q5_WRAPPER" class="question shortanswer">
<legend id="Q5_LEGEND" class="sr-only">
<label for="Q5_1"></label>
</legend><span id="Q5_QUESTION_TEXT"><a id="Q5_HEADING" class="question-heading anchor"></a><label for="Q5_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">City</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q5_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q5_1" id="Q5_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q5_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 6 before continuing. </div>
</fieldset><!--Q5_END-->
<!--Q6_START-->
<fieldset id="Q6_WRAPPER" class="question shortanswer">
<legend id="Q6_LEGEND" class="sr-only">
<label for="Q6_1"></label>
</legend><span id="Q6_QUESTION_TEXT"><a id="Q6_HEADING" class="question-heading anchor"></a><label for="Q6_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">State</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q6_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<select class="form-control" name="Q6_1" id="Q6_1" role="listbox">
<option id="Q6_1_0" value="" selected="selected" role="option" aria-selected="true"> </option>
<option id="Q6_1_1" value="Alabama - AL" role="option" aria-selected="false"> Alabama - AL </option>
<option id="Q6_1_2" value="Alaska - AK" role="option" aria-selected="false"> Alaska - AK </option>
<option id="Q6_1_3" value="Arizona -AZ" role="option" aria-selected="false"> Arizona -AZ </option>
<option id="Q6_1_4" value="Arkansas -AR" role="option" aria-selected="false"> Arkansas -AR </option>
<option id="Q6_1_5" value="California -CA" role="option" aria-selected="false"> California -CA </option>
<option id="Q6_1_6" value="Colorado -CO" role="option" aria-selected="false"> Colorado -CO </option>
<option id="Q6_1_7" value="Connecticut -CT" role="option" aria-selected="false"> Connecticut -CT </option>
<option id="Q6_1_8" value="Delaware -DE" role="option" aria-selected="false"> Delaware -DE </option>
<option id="Q6_1_9" value="Florida -FL" role="option" aria-selected="false"> Florida -FL </option>
<option id="Q6_1_10" value="Georgia -GA" role="option" aria-selected="false"> Georgia -GA </option>
<option id="Q6_1_11" value="Hawaii -HI" role="option" aria-selected="false"> Hawaii -HI </option>
<option id="Q6_1_12" value="Idaho -ID" role="option" aria-selected="false"> Idaho -ID </option>
<option id="Q6_1_13" value="Illinois -IL" role="option" aria-selected="false"> Illinois -IL </option>
<option id="Q6_1_14" value="Indiana -IN" role="option" aria-selected="false"> Indiana -IN </option>
<option id="Q6_1_15" value="Iowa -IA" role="option" aria-selected="false"> Iowa -IA </option>
<option id="Q6_1_16" value="Kansas -KS" role="option" aria-selected="false"> Kansas -KS </option>
<option id="Q6_1_17" value="Kentucky -KY" role="option" aria-selected="false"> Kentucky -KY </option>
<option id="Q6_1_18" value="Louisiana -LA" role="option" aria-selected="false"> Louisiana -LA </option>
<option id="Q6_1_19" value="Maine -ME" role="option" aria-selected="false"> Maine -ME </option>
<option id="Q6_1_20" value="Maryland -MD" role="option" aria-selected="false"> Maryland -MD </option>
<option id="Q6_1_21" value="Massachusetts -MA" role="option" aria-selected="false"> Massachusetts -MA </option>
<option id="Q6_1_22" value="Michigan -MI" role="option" aria-selected="false"> Michigan -MI </option>
<option id="Q6_1_23" value="Minnesota -MN" role="option" aria-selected="false"> Minnesota -MN </option>
<option id="Q6_1_24" value="Mississippi -MS" role="option" aria-selected="false"> Mississippi -MS </option>
<option id="Q6_1_25" value="Missouri -MO" role="option" aria-selected="false"> Missouri -MO </option>
<option id="Q6_1_26" value="Montana -MT" role="option" aria-selected="false"> Montana -MT </option>
<option id="Q6_1_27" value="Nebraska -NE" role="option" aria-selected="false"> Nebraska -NE </option>
<option id="Q6_1_28" value="Nevada -NV" role="option" aria-selected="false"> Nevada -NV </option>
<option id="Q6_1_29" value="New Hampshire -NH" role="option" aria-selected="false"> New Hampshire -NH </option>
<option id="Q6_1_30" value="New Jersey -NJ" role="option" aria-selected="false"> New Jersey -NJ </option>
<option id="Q6_1_31" value="New Mexico -NM" role="option" aria-selected="false"> New Mexico -NM </option>
<option id="Q6_1_32" value="New York -NY" role="option" aria-selected="false"> New York -NY </option>
<option id="Q6_1_33" value="North Carolina -NC" role="option" aria-selected="false"> North Carolina -NC </option>
<option id="Q6_1_34" value="North Dakota -ND" role="option" aria-selected="false"> North Dakota -ND </option>
<option id="Q6_1_35" value="Ohio -OH" role="option" aria-selected="false"> Ohio -OH </option>
<option id="Q6_1_36" value="Oklahoma -OK" role="option" aria-selected="false"> Oklahoma -OK </option>
<option id="Q6_1_37" value="Oregon -OR" role="option" aria-selected="false"> Oregon -OR </option>
<option id="Q6_1_38" value="Pennsylvania -PA" role="option" aria-selected="false"> Pennsylvania -PA </option>
<option id="Q6_1_39" value="Rhode Island -RI" role="option" aria-selected="false"> Rhode Island -RI </option>
<option id="Q6_1_40" value="South Carolina -SC" role="option" aria-selected="false"> South Carolina -SC </option>
<option id="Q6_1_41" value="South Dakota -SD" role="option" aria-selected="false"> South Dakota -SD </option>
<option id="Q6_1_42" value="Tennessee -TN" role="option" aria-selected="false"> Tennessee -TN </option>
<option id="Q6_1_43" value="Texas -TX" role="option" aria-selected="false"> Texas -TX </option>
<option id="Q6_1_44" value="Utah -UT" role="option" aria-selected="false"> Utah -UT </option>
<option id="Q6_1_45" value="Vermont -VT" role="option" aria-selected="false"> Vermont -VT </option>
<option id="Q6_1_46" value="Virginia -VA" role="option" aria-selected="false"> Virginia -VA </option>
<option id="Q6_1_47" value="Washington -WA" role="option" aria-selected="false"> Washington -WA </option>
<option id="Q6_1_48" value="West Virginia -WV" role="option" aria-selected="false"> West Virginia -WV </option>
<option id="Q6_1_49" value="Wisconsin -WI" role="option" aria-selected="false"> Wisconsin -WI </option>
<option id="Q6_1_50" value="Wyoming -WY" role="option" aria-selected="false"> Wyoming -WY </option>
<option id="Q6_1_51" value="Alberta -XA" role="option" aria-selected="false"> Alberta -XA </option>
<option id="Q6_1_52" value="British Columbia - XC" role="option" aria-selected="false"> British Columbia - XC </option>
<option id="Q6_1_53" value="Manitoba - XM" role="option" aria-selected="false"> Manitoba - XM </option>
<option id="Q6_1_54" value="New Brunswick - XB" role="option" aria-selected="false"> New Brunswick - XB </option>
<option id="Q6_1_55" value="Newfoundland - XW" role="option" aria-selected="false"> Newfoundland - XW </option>
<option id="Q6_1_56" value="Northwest Territories - XT" role="option" aria-selected="false"> Northwest Territories - XT </option>
<option id="Q6_1_57" value="Nova Scotia - XN" role="option" aria-selected="false"> Nova Scotia - XN </option>
<option id="Q6_1_58" value="Ontario - XO" role="option" aria-selected="false"> Ontario - XO </option>
<option id="Q6_1_59" value="Prince Edward Island - XP" role="option" aria-selected="false"> Prince Edward Island - XP </option>
<option id="Q6_1_60" value="Quebec - XQ" role="option" aria-selected="false"> Quebec - XQ </option>
<option id="Q6_1_61" value="Saskatchewan - XS" role="option" aria-selected="false"> Saskatchewan - XS </option>
<option id="Q6_1_62" value="Nunavut - XV" role="option" aria-selected="false"> Nunavut - XV </option>
<option id="Q6_1_63" value="Yukon Territory - XY" role="option" aria-selected="false"> Yukon Territory - XY </option>
<option id="Q6_1_64" value="Province Unknown - OT" role="option" aria-selected="false"> Province Unknown - OT </option>
</select>
</div>
</div>
<div id="Q6_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 7 before continuing. </div>
</fieldset><!--Q6_END-->
<!--Q7_START-->
<fieldset id="Q7_WRAPPER" class="question shortanswer">
<legend id="Q7_LEGEND" class="sr-only">
<label for="Q7_1"></label>
</legend><span id="Q7_QUESTION_TEXT"><a id="Q7_HEADING" class="question-heading anchor"></a><label for="Q7_1" class="question-text"><span face="Verdana" font-size="14px" style="font-size: 14px; font-family: Verdana;"><span
face="Verdana">Zip</span></span><span style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q7_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q7_1" id="Q7_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q7_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 8 before continuing. </div>
</fieldset><!--Q7_END-->
<!--Q9_START-->
<fieldset id="Q9_WRAPPER" class="question shortanswer">
<legend id="Q9_LEGEND" class="sr-only">
<label for="Q9_1"></label>
</legend><span id="Q9_QUESTION_TEXT"><a id="Q9_HEADING" class="question-heading anchor"></a><label for="Q9_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Phone number</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q9_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q9_1" id="Q9_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q9_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 9 before continuing. </div>
</fieldset><!--Q9_END-->
<!--Q8_START-->
<fieldset id="Q8_WRAPPER" class="question shortanswer">
<legend id="Q8_LEGEND" class="sr-only">
<label for="Q8_1"></label>
</legend><span id="Q8_QUESTION_TEXT"><a id="Q8_HEADING" class="question-heading anchor"></a><label for="Q8_1" class="question-text"><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); font-size: 14px; font-family: Verdana;"><span style="color: rgb(0, 0, 0); font-size: 16px;">Email </span><span style="background-color: rgb(255, 255, 255);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q8_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="email" class="form-control" name="Q8_1" id="Q8_1" maxlength="255" placeholder="Email" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q8_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 10 before continuing. </div>
<div id="Q8_1EmailAddress" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Your answer to question 10 must be a valid email address. </div>
</fieldset><!--Q8_END-->
<!--Q28_START-->
<fieldset id="Q28_WRAPPER" class="question chooseone list">
<legend id="Q28_LEGEND" class="sr-only">
</legend><span id="Q28_QUESTION_TEXT"><a id="Q28_HEADING" class="question-heading anchor"></a><span class="question-text"><span style="font-family: Verdana;">Is your shipping address the same as your contact address? </span><span
color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)" style="color: rgb(255, 0, 0); font-size: 14px; font-family: Verdana;">*</span></span></span>
<div class="response-area" role="radiogroup" aria-labelledby="Q28_QUESTION_TEXT">
<ol class="response-set">
<li id="Q28C1" class="response select-area"><input type="radio" name="Q28" value="1" id="Q28_1" role="radio" aria-checked="false"><label for="Q28_1" class="choice-text">Yes</label></li>
<li id="Q28C2" class="response select-area"><input type="radio" name="Q28" value="2" id="Q28_2" role="radio" aria-checked="false"><label for="Q28_2" class="choice-text">No</label></li>
</ol>
</div>
<div id="Q28ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 11 before continuing. </div>
</fieldset><!--Q28_END-->
<input type="hidden" id="CurrentPageId" name="CurrentPageId" value="1"><input type="hidden" id="SurveyId" name="SurveyId" value="705E3ED85708C4B5"><input type="hidden" id="SessionKey" name="SessionKey"
value="849de702-22f7-43b6-852b-d175d54a7ee7_-1348377790">
</div>
</div>
<div class="row">
<div class="col-xs-6 col-xs-offset-3 col-md-4 col-md-offset-4">
<div class="progress progress-incomplete-color" id="PB_1">
<div class="progress-bar progress-complete-color" role="progressbar" tabindex="0" aria-valuenow="14" aria-valuemin="0" aria-valuemax="100" aria-label="14%" style="width:14%;">
<span class="sr-only">14% Complete</span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-10 col-md-offset-1">
<p id="BA"><input id="BN" type="submit" name="next" class="btn btn-primary button-text button-next" role="button" value="Next"></p>
</div>
</div>
<div class="row">
<div class="col-md-10 col-md-offset-1 text-center">
<small id="TL1" class="tagline perseus-link"> Powered by Verint: <a href="https://www.verint.com/experience-management/" target="_blank">Experience Management - Verint</a>
</small>
</div>
</div>
</div>
</form>Text Content
Survey You should have recently received a letter and/or a postcard informing you a problem has been identified in the Philips M5071A (adult) and M5072A (infant/child) AED pads that could pose a risk for patients or users. Unexpired M5071A Adult pads cartridges with a LOT number beginning with “Y” will be replaced, free-of-charge. To learn more about the SMART Pads Medical Device Correction, visit www.philips.com/pads-notice. In order to do this, we need you to verify some information about you and your AED(s). Key information fields are marked with an asterisk (*) please provide the information to the best of your ability. TELL US ABOUT YOURSELF Name * Please answer question 3 before continuing. Organization/Company (if applicable) Street address * Please answer question 5 before continuing. City * Please answer question 6 before continuing. State * Alabama - AL Alaska - AK Arizona -AZ Arkansas -AR California -CA Colorado -CO Connecticut -CT Delaware -DE Florida -FL Georgia -GA Hawaii -HI Idaho -ID Illinois -IL Indiana -IN Iowa -IA Kansas -KS Kentucky -KY Louisiana -LA Maine -ME Maryland -MD Massachusetts -MA Michigan -MI Minnesota -MN Mississippi -MS Missouri -MO Montana -MT Nebraska -NE Nevada -NV New Hampshire -NH New Jersey -NJ New Mexico -NM New York -NY North Carolina -NC North Dakota -ND Ohio -OH Oklahoma -OK Oregon -OR Pennsylvania -PA Rhode Island -RI South Carolina -SC South Dakota -SD Tennessee -TN Texas -TX Utah -UT Vermont -VT Virginia -VA Washington -WA West Virginia -WV Wisconsin -WI Wyoming -WY Alberta -XA British Columbia - XC Manitoba - XM New Brunswick - XB Newfoundland - XW Northwest Territories - XT Nova Scotia - XN Ontario - XO Prince Edward Island - XP Quebec - XQ Saskatchewan - XS Nunavut - XV Yukon Territory - XY Province Unknown - OT Please answer question 7 before continuing. Zip * Please answer question 8 before continuing. Phone number * Please answer question 9 before continuing. Email * Please answer question 10 before continuing. Your answer to question 10 must be a valid email address. Is your shipping address the same as your contact address? * 1. Yes 2. No Please answer question 11 before continuing. 14% Complete Powered by Verint: Experience Management - Verint