I am * --- Patient Parent/Guardian/Caregiver/Spouse Other
Specify Other *
Reporter Name *
Email Address *
Select the product for which you require support * --- Dexcom G6 Dexcom G7 Tandem
G6 Dexcom Account Username *
G6 Specify Other Insertion Site
G6 Was Paracetamol Taken? * --- Yes No
G6 Display Device * --- Apple Smartphone Android Smartphone Tandem Pump Receiver Smartphone and Tandem Pump Other - Specify
G6 Specify Other Device
G6 Is this a Sensor, Transmitter, App, or Receiver Issue? * -- Sensor Transmitter App Receiver
G6 Sensor Error Type * --- Sensor Error - Wait 3 hours Sensor Fail Alert Inaccurate Readings Calibration Error Poor Patch Adhesion Needle Retraction/Deployment Issue Transmitter Holder Detached Other - Specify
G6 How long did the issue last? * --- Less that 1 hour 1 - 3 hours More than 3 hours
G6 Which alert displays? --- Calibrate Now Calibrate in 15 Mins Repeated Calibration Prompt
G6 Did you put an Overlay Patch On? --- I used Dexcom Overlay Patch I used Other Adhesive I used both Dexcom Patch and Other Adhesive I did not apply any overlay patches
G6 Was the skin exposed to water within 12 hours after insertion? --- Yes No
G6 Is the applicator needle exposed? * --- Yes No
G6 Specify Sensor Error Type
G6 Transmitter Error Type --- Signal Loss - Wait 30 Mins to Reconnect Critical Low Battery Transmitter Failed /Not Found Other - Specify
G6 Specify Transmitter Error Type
G7 Dexcom Account Username *
G7 Is this a Sensor, App, or Receiver Issue? * -- Sensor App Receiver
G7 Sensor Error Type * --- Sensor Error - Wait 3 hours Sensor Fail Alert Inaccurate Readings Calibration Error Poor Patch Adhesion Needle Retraction/Deployment Issue Signal Loss - Wait 30 Mins to Reconnect Pairing Failed No Sensor Restart Transmitter Holder Detached Other - Specify
G7 How long did the issue last? * --- Less that 1 hour 1 - 3 hours More than 3 hours
G7 Which alert displays? --- Calibrate Now Calibrate in 15 Mins Repeated Calibration Prompt
G7 Did you put an Overlay Patch On? --- I used Dexcom Overlay Patch I used Other Adhesive I used both Dexcom Patch and Other Adhesive I did not apply any overlay patches
G7 Was the skin exposed to water within 12 hours after insertion? --- Yes No
G7 Is the applicator needle exposed? * --- Yes No
G7 Is this a new Sensor? --- Yes No
G7 Specify Sensor Error Type
G7 App Error Type --- No Data (Follow App) Server Error No Alerts & Alarms Received
G7 Specify Receiver Error Type
Insulin Used --- Humalog Novorapid Other
Specify other insulin
Is this a cartridge, infusion set, pump accessory or pump touchscreen issue? --- Infusion Set Cartridge Accessory Cracked/Shattered Tandem Pump Screen
Infusion Set Type --- AutoSoft 90 AutoSoft 30 Trusteel
Infusion Set LOT Nr
Cartridge LOT Nr
Are you able to load a new cartridge and resume Insulin delivery? * --- Yes No
Select Accessory (Lost items are not replacable/reportable) --- USB rubber door Pump Case Screen Protector Other
Specify Tandem Accessory Issue
Is the Touchscreen cracked or shattered? --- Cracked Shattered
How did the pump screen become damaged?
