FORM OF EXCLUSIVE DISTRIBUTOR AGREEMENTExclusive Distributor Agreement • March 28th, 2014 • Venaxis, Inc. • In vitro & in vivo diagnostic substances • Colorado
o Initial Vigilance Report o Final Vigilance Report 1. Competent Authority: (Destination) Address : 2. Reporting firm name : a) o Manufacturer oAuthorized representative within EEA b) Address : c) Contact person name : d) Telephone number : e) Telefax number : f) Report date : 3. Manufacturer (if not already provided in point 2) a) Name : b) Address : 4. Information about incident a) Medical device commercial name : b) Kind of device (e.g. pacemaker, catheter, etc) (*)1 c) Model or catalogue number : d) Serial number(s) or lot number(s) : e) Accessories/associated devices (if applicable) : f) Software version (if applicable) : g) Identification number of Notified Body involved in conformity assessment (if applicable) : h) Reporting firm is aware of other similar incidents having an impact on the current report : o Yes o No i) If yes, the countries to which these have been reported, and the report reference numbers are listed as follows :
