Out-of-Plane Needle Guidance End User Survey

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* 5. Procedure(s) Performed

Truncial Nerve Block

Peripheral Nerve block

Fine Needle Aspiration (FNA)

CVC Placement

PICC Line

Arterial Line

Peripheral IV

Other (please specify)

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* 6. Anatomy Targeted

Arm

Leg

Neck

Abdomen

Back

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
Rate the ease of assembly of the bracket and needle guide.	Rate the ease of assembly of the bracket and needle guide. 1-Low Satisfaction	Rate the ease of assembly of the bracket and needle guide. 2	Rate the ease of assembly of the bracket and needle guide. 3	Rate the ease of assembly of the bracket and needle guide. 4	Rate the ease of assembly of the bracket and needle guide. 5-High Satisfaction
Comment
Based on product design, rate the ease of use of the needle guide during the procedure.	Based on product design, rate the ease of use of the needle guide during the procedure. 1-Low Satisfaction	Based on product design, rate the ease of use of the needle guide during the procedure. 2	Based on product design, rate the ease of use of the needle guide during the procedure. 3	Based on product design, rate the ease of use of the needle guide during the procedure. 4	Based on product design, rate the ease of use of the needle guide during the procedure. 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 guide enable out-of-plane needle guidance compared to expectations?	How well did the guide enable out-of-plane needle guidance compared to expectations? 1-Low Satisfaction	How well did the guide enable out-of-plane needle guidance compared to expectations? 2	How well did the guide enable out-of-plane needle guidance compared to expectations? 3	How well did the guide enable out-of-plane needle guidance compared to expectations? 4	How well did the guide enable out-of-plane needle guidance compared to expectations? 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 guidance product?

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

Comment

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* 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)

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* 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

5-High Satisfaction

N/A

1-Low Satisfaction

5-High Satisfaction

N/A

Comment

Out-of-Plane Needle Guidance 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 guidance product?

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* 9. Which ultrasound cover was used during the needle guided procedure?

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* 10. How well did the ultrasound cover serve as a sterile barrier? (Rank satisfaction with 1 being the lowest and 5 being the highest)

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