Product Evaluation
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1
2Product Evaluation & Standardisation Committee
(PESC)
PART A – Clinical Product Evaluation Request
To be completed by the Product Evaluator
PRODUCT INFORMATION
Description of Clinical Product [Attach relevant brochures]
Description of Clinical Application
Brand Name
Manufacturer
Model Number
Model Name
Price
$
REASON FOR REQUEST
Reason for Evaluation:
Upgrade
Substitution
Review
Tender
New to Market
Provide evidence of the advantages of this product (attach relevant supporting documents)
Consider the patient, staff and hospital
SUPPLIER INFORMATION
Name of Supplier
Address
Phone
Facsimile
E-Mail
Web Address
Representative
Phone
Mobile
E-Mail
EVALUATION REQUESTED BY (PRODUCT EVALUATOR)
Name
Organisation
Phone
Position
1.
Does the evaluation/use of this product constitute a change in the scope of your practice?
No
Yes
Details :
If so, please discuss with your Head of Department as to liaison with the Medical Credentialing Committee at your hospital. Hospital
Ethics Committee endorsement may also need to be sought.
Health acknowledges the use of concepts and wording (with permission) of the NSW Peak Purchasing Council.
Revised: Feb 11 Endorsed by Peak PESC: Mar 11
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Parent category: Business