Covers End User
*
1.
Country
(Required.)
2.
Facility
*
3.
Product Used
(Required.)
System drape
Surgi-Tip™
CIV-Flex™
PEELSafe Advantage™
Polyethylene
CIV-Clear™
NeoGuard™
Latex
4.
Item Number(s) Used
*
5.
Procedure(s) Performed
(Required.)
Intra-operative
Biopsy/FNA
Vascular access
Regional anesthesia
Transvaginal/endovaginal
Transrectal
TEE/TOE
Other (please specify)
*
6.
Anatomy Targeted
(Required.)
Prostate
Uterus/ovary
Heart
Abdomen
Head/Neck
Breast
Chest
Extremities
Other (please specify)
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
Based on product design, rate the ease of cover application to the probe using sterile technique.
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
Based on product design, rate the ease of use of the cover removal 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
How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material?
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
8.
Based on your clinical expertise, do you believe there is added patient risk associated with the use of this product?
No
Yes (if yes, please explain in Comment box below)
Comment
9.
Please provide your email address in order for CIVCO to respond to any concerns.
