Covers End User Survey

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* 3. Product Used

System drape

Surgi-Tip™

CIV-Flex™

PEELSafe Advantage™

Polyethylene

CIV-Clear™

NeoGuard™

Latex

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* 4. Item Number(s) Used

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* 5. Procedure(s) Performed

Intra-operative

Biopsy/FNA

Vascular access

Regional anesthesia

Transvaginal/endovaginal

Transrectal

TEE/TOE

Other (please specify)

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* 6. Anatomy Targeted

Prostate

Uterus/ovary

Heart

Abdomen

Head/Neck

Breast

Chest

Extremities

Other (please specify)

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* 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.	Based on product design, rate the ease of cover application to the probe using sterile technique. 1-Low Satisfaction	Based on product design, rate the ease of cover application to the probe using sterile technique. 2	Based on product design, rate the ease of cover application to the probe using sterile technique. 3	Based on product design, rate the ease of cover application to the probe using sterile technique. 4	Based on product design, rate the ease of cover application to the probe using sterile technique. 5-High Satisfaction
Comment
Based on product design, rate the ease of use of the cover removal in the clinical setting.	Based on product design, rate the ease of use of the cover removal in the clinical setting. 1-Low Satisfaction	Based on product design, rate the ease of use of the cover removal in the clinical setting. 2	Based on product design, rate the ease of use of the cover removal in the clinical setting. 3	Based on product design, rate the ease of use of the cover removal in the clinical setting. 4	Based on product design, rate the ease of use of the cover removal in the clinical setting. 5-High Satisfaction
Comment
How satisfied are you with the quality of this product?	How satisfied are you with the quality of this product? 1-Low Satisfaction	How satisfied are you with the quality of this product? 2	How satisfied are you with the quality of this product? 3	How satisfied are you with the quality of this product? 4	How satisfied are you with the quality of this product? 5-High Satisfaction
Comment
How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material?	How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material? 1-Low Satisfaction	How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material? 2	How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material? 3	How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material? 4	How well did the cover serve as a barrier to prevent transfer of microorganisms, bodily fluids and particulate material? 5-High Satisfaction
Comment

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* 8. Based on your clinical expertise, do you believe there is added patient risk associated with the use of this product?

Yes (if yes, please explain in Comment box below)

Comment

Covers End User

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* 1. Country

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* 2. Facility

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* 3. Product Used

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* 4. Item Number(s) Used

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* 5. Procedure(s) Performed

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* 6. Anatomy Targeted

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* 7. Rate satisfaction on a scale of 1 to 5 (1 being the lowest level of satisfaction & 5 being the highest level of satisfaction)

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* 8. Based on your clinical expertise, do you believe there is added patient risk associated with the use of this product?

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* 9. Please provide your email address in order for CIVCO to respond to any concerns.