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Guidelines for Completing Vendor Complaint Form

Vendor Complaint Form

 

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University Hospital

VENDOR COMPLAINT REPORT

DO NOT WRITE IN THE BLOCK, FOR PURCHASING ONLY

UH Purchasing

65 Bergen Street,
Newark, NJ 07109

Vendor ID No. Commodity Code. Complaint No.

Status:

_ OPEN

_CLOSED

Other:

_ SPECIFICATION _VENDOR _CANCELLATION_DEBARMENT _SUSPENSION

Purchasing Department Fiscal Year Date Received

INSTRUCTIONS TO DEPARTMENT. Please type or print. Complete Sections 1 to 5 below, Retain Gold Copy for your records.Submit White, Canary and Pink Copies to the Purchasing Department, noted above.

DO NOT FORWARD COMPLETED FORM TO VENDOR.

1.NAME AND ADDRESS OF DEPARTMENT 2.NAME AND ADDRESS OF VENDOR
PERSON TO CONTACT TELEPHONE NUMBER PERSON TO CONTACT TELEPHONE NUMBER

3. Purchase Authorization (Check One):

Purchase Order No_____________________________________________

Requisition No____________________________________

Other____________________________________________

Enter Total Cost of Commodity or Service: $___________________________

4. CHECK NATURE OF COMPLAINT (S)

_ Not Delivered (or)

_Late Delivery

_ Product or Service Not Meeting Specifications

_ Unsatisfactory Service or Performance of Product

_ Incorrect Price

_Other______________________________________

5. DETAILED REPORT (Givedetailed explanation and attach additional sheets If necessary, Please print and type)

_ Check here if continued on separate sheets.

SUBMITTED BY (Print or Type) NAME TITLE DATE

VENDOR'S REPORT

INSTRUCTIONS TO VENDOR: Please print or type. Response to Purchasing Department should include corrective action to be initiated. Attach additional sheets if necessary. Retain Pink Copy for you records and return Canary to Purchasing Department, at the address noted above.

 

SUBMITTED BY (Print or Type) NAME TITLE DATE