OR/CSS New Product Request Form

Requested by:

Submitted by:

Date Submitted +

Requestor email address:

Requestor phone number:

Service:

At what hospital will this product be used? *

Brigham and Women's Hospital

Faulkner Hospital

Foxboro Day Surgery

Do you, or to your knowledge does a family member (which includes a spouse, dependent child, or domestic partner), have a financial interest in this company? *

Yes

*If you answered "yes", you must update or complete the Partners Disclosure Statement. By completing this form, you grant permission to the Periop Committee to access your Partners Disclosure Statement in Insight to review financial interests that are relevant to this purchase request. Please do one of the following steps: Go to https://insight.partners.org/public/ and, in the Conflict of Interest module, either complete your Annual Disclosure form if you have not already done so, or if you have new interests to report since the time you last completed your Annual Disclosure form, then complete an Update form. If you're unable to access the Conflict of Interest module, please contact Anne Saint Cloud in the Office of Interactions with Industry, who can provide you with access to a form.

Type of Request

Type of Product Request: *

Single Case Use	Replacement of Current
Addition to Inventory	Trial (Please answer associated questions)

Is item being used in an IRB study?

Yes

Trial Duration (number of cases or months):

If yes, Surgeon participants/PI:

IRB#:

Expected Outcome of Trial:

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Product Information

Product Name: *

Manufacturer: *

Catalog Number/ PeopleSoft Number: *

Cost Per Each:

Vendor Rep Name:

Vendor Email/Phone:

Is product FDA Approved?

Yes

Please Attach Quote if Available

Brief Description of Product: *

On what procedure(s) will this product be used (for single case use please give date of surgery and MRN): *

Estimated Usage:

Per:

Will this item be on a preference card?

Yes

If yes, please indicate surgeon name and procedure:

Is additional physician or staff training or proctoring required?

If so, please explain:

Rationale for Request

Description of Product Use: *

Reason for Request: *

New Procedure

Offers Clinical Advantage

Improves Efficiency

Reduces Cost

Justification of Product Request: *

What other competing devices exist?/What is currently offered? *

What are the differences between the requested product and the current product(s)? *

Can the current product be discontinued from inventory?

Yes

Current product information (Catalog/PeopleSoft#):

0/255 characters

Please attach any research, white papers, data and/or literature that support your request:

I have reviewed this request with my Chief and I have his/her approval: *

Yes

Comment: Comment:

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You may be asked to provide detailed financial justification and/or patient care improvement data to substantiate requests of high dollar value or with major program implications.