Out-of-Plane Needle Guidance End User
*
1.
Country
(Required.)
2.
Facility
*
3.
Product Used
(Required.)
AccuSITE™
L25
4.
Item Number(s) Used
*
5.
Procedure(s) Performed
(Required.)
Truncial Nerve Block
Peripheral Nerve block
Fine Needle Aspiration (FNA)
CVC Placement
PICC Line
Arterial Line
Peripheral IV
Other (please specify)
*
6.
Anatomy Targeted
(Required.)
Arm
Leg
Neck
Abdomen
Back
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
Rate the ease of assembly of the bracket and needle guide.
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
Based on product design, rate the ease of use of the needle guide during the procedure.
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 guide enable out-of-plane needle guidance compared to expectations?
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 guidance product?
No
Yes (if yes, please explain in Comment box below)
Comment
9.
Which ultrasound cover was used during the needle guided procedure?
CIV-Flex™
PEELSafe Advantage™
Envision™
Polyethylene
Surgi-Tip™
Latex
System Drape
Other (please specify)
10.
How well did the ultrasound cover serve as a sterile barrier? (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
11.
Please provide your email address in order for CIVCO to respond to any concerns.
