AccuCARE Stepper, Stabilizer & Grids End User
*
1.
Country
(Required.)
2.
Facility
*
3.
Product(s) Used
(Required.)
Classic Stepper
EX3™ Stepper Stabilizer System
Multi-Purpose Workstation
Template grid 14GA
Template grid 17/18GA
System drape
*
4.
Procedure(s) Performed
(Required.)
Cryotherapy
HDR Brachytherapy
LDR Brachytherapy
SpaceOAR hydrogel placement
Transperineal biopsy
Other (please specify)
*
5.
Anatomy Targeted
(Required.)
Prostate
Pelvis
Other (please specify)
6.
Rate satisfaction on a scale of 1 to 5 (1 being the lowest level of satisfaction & 5 being the highest level of satisfaction)
1-Low Satisfaction
2
3
4
5-High Satisfaction
Based on product design, rate the ease of use of the product in the clinical setting.
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
How satisfied are you with the quality of this product?
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
7.
Rate satisfaction on a scale of 1 to 5 (1 being the lowest level of satisfaction & 5 being the highest level of satisfaction)
1-Low Satisfaction
2
3
4
5-High Satisfaction
N/A
How well did the template grid aid in positioning and placement of devices?
1-Low Satisfaction
2
3
4
5-High Satisfaction
N/A
Comment
8.
Based on your clinical expertise, do you believe there is added patient risk associated with the use of a template grid?
No
Yes (if yes, please explain in Comment box below)
Comment
9.
Based on your clinical expertise, do you believe there is added patient risk associated with the use of a stepper stabilizer system?
No
Yes (if yes, please explain in Comment box below)
Comment
10.
Did you use the stepper stabilizer system drape during this procedure?
No
Yes
11.
How well did the system drape serve as a barrier to prevent contamination of the stepper? (Rank satisfaction with 1 being the lowest and 5 being the highest)
1-Low Satisfaction
2
3
4
5-High Satisfaction
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
12.
Please provide your email address in order for CIVCO to respond to any concerns.
