New Clinical Product Request Form Instructions
This file contains essential instructions for filling out the New Clinical Product Request Form. It outlines the necessary fields and provides guidance for effective completion. Users aiming to submit a new product or equipment request should find this document invaluable.
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How do I fill this out?
Filling out this form requires attention to detail and accurate information. Begin by providing your contact information and product details. Ensure to review the instructions carefully before submission.
How to fill out the New Clinical Product Request Form Instructions?
1
Read the instructions carefully.
2
Complete all required fields accurately.
3
Attach necessary supplemental information.
4
Initial the Conflict of Interest Statement.
5
Submit the completed form as instructed.
Who needs the New Clinical Product Request Form Instructions?
1
Physicians requesting new medical equipment.
2
Department heads for product evaluations.
3
Staff involved in clinical trials with new technology.
4
Sales representatives seeking product approval.
5
Clinical researchers needing product details for studies.
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What are the instructions for submitting this form?
To submit this form, send it to the department's administrative office via email at admin@universityhospital.com or fax to (555) 123-4567. For online submissions, use the hospital's secure web portal. Physical forms can be mailed to University Hospital, 100 Health St, Newark, NJ 07103.
What are the important dates for this form in 2024 and 2025?
Important dates for form submission are as follows: Submit the request form by March 15, 2024, for first quarter evaluations. Requests must be in by August 15, 2024, for second quarter evaluations. Ensure all submissions align with departmental deadlines for the following year.
What is the purpose of this form?
The purpose of this form is to systematically evaluate new clinical products. It serves to gather necessary information from healthcare providers for informed decision-making regarding new medical devices. By completing this form, stakeholders can ensure that all relevant data is considered during the product evaluation process.
Tell me about this form and its components and fields line-by-line.
- 1. Date Requested: The date when the request is submitted.
- 2. Physician Stakeholder: Information about the requesting physician.
- 3. Name & title of person completing this form: Who is filling out the form.
- 4. Manufacturer: The manufacturer of the product.
- 5. Name of New Product or Device: The specific product being requested.
- 6. Product Number: Identifier for the product, if known.
- 7. Sales Representative: Contact information for the sales rep.
- 8. New Technology or Upgrade: Use Yes/No for identifying technology advancements.
- 9. Procedure Types: Purpose and uses of the product.
- 10. Clinical Improvements: Clinical benefits the product offers.
- 11. Evidence Based Practice Literature: Literature supporting the product claims.
- 12. Disposables or Instruments Needed: Details of additional materials required.
- 13. Annual Volume of Procedures: Anticipated usage metrics.
- 14. FDA Approval: Status regarding FDA approval.
- 15. Product Evaluation Required: If initial evaluations are needed.
- 16. Clinical Trial Involvement: Relation to any clinical trials.
- 17. Research Study Involvement: If the product is part of an IRB study.
- 18. Additional Implementation Costs: Any extra costs related to implementing the product.
- 19. Awareness of Product: How the requestor learned about the product.
- 20. Conflict of Interest Statement: Disclosure of any potential conflicts.
What happens if I fail to submit this form?
Failure to submit this form may lead to delays in the evaluation of the requested product. Without this form, the product may not be considered for inclusion in the formulary. Ensure timely submission to facilitate product review.
- Delays in Product Evaluation: Your request might not be processed on time.
- Ineligibility for Product Review: Without submission, the product cannot be reviewed.
- Lack of Documentation: Missing documentation could hinder the request.
How do I know when to use this form?
- 1. Requesting New Products: To evaluate new products for clinical use.
- 2. Replacement Product Evaluation: For replacing outdated or ineffective devices.
- 3. Upgrades to Existing Technology: To request upgrades on existing medical equipment.
Frequently Asked Questions
What is the purpose of this form?
The New Clinical Product Request Form is designed for healthcare providers to request evaluation and inclusion of new medical products.
How can I edit the PDF?
Use the PrintFriendly PDF editor, click on the text you want to change, and make your edits directly.
Is the form suitable for all types of medical products?
Yes, the form can be used for new, replacement, and product evaluations across various medical equipment.
Can I leave fields blank?
No, please ensure all required fields are completed to avoid delays in processing your request.
How do I submit the completed form?
Follow the submission instructions provided at the end of the document.
What if I have questions while filling out the form?
Contact your department head or the relevant regulatory body for assistance.
Are there deadlines for submitting this form?
Submit the form as soon as the need arises to ensure timely evaluation.
Where can I find additional resources?
Refer to your hospital’s or department’s guidelines for more information.
Is this form necessary for all equipment requests?
Yes, all new product requests must be accompanied by this form.
What happens after I submit the request?
Your request will be reviewed by the Executive Value Analysis Committee.
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