A-BOX System Post Market Surveillance Protocol

Location and Physician

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* 1. Hospital Name

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* 2. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 3. Physician Name

Patient Demographics

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* 4. Patient Gender

Male

Female

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

Procedure

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* 8. Operation Date and Time

Date / Time

Date

Time

AM/PM

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* 9. Total Operative Time (00:00)

Implants used

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* 10. How well did the following areas meet your needs?

	Extremely well	Very well	Slightly well	Not Well at all
A-BOX Device	A-BOX Device Extremely well	A-BOX Device Very well	A-BOX Device Slightly well	A-BOX Device Not Well at all
A-BOX Device Instruments	A-BOX Device Instruments Extremely well	A-BOX Device Instruments Very well	A-BOX Device Instruments Slightly well	A-BOX Device Instruments Not Well at all
A-BOX Tray	A-BOX Tray Extremely well	A-BOX Tray Very well	A-BOX Tray Slightly well	A-BOX Tray Not Well at all
Marketing/Training Support	Marketing/Training Support Extremely well	Marketing/Training Support Very well	Marketing/Training Support Slightly well	Marketing/Training Support Not Well at all
Innovasis Support	Innovasis Support Extremely well	Innovasis Support Very well	Innovasis Support Slightly well	Innovasis Support Not Well at all

Please explain any area we did not meet your needs.

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* 11. Any other suggestions for possible future improvements?

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* 12. When using the A-BOX System, did the Patient(s) progress as expected?

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* 13. For the A-BOX System that you used briefly, but stopped. Why did you stop using it?

A-Box Device

A-BOX Instruments

A-BOX Tray

Innovasis Headquarters Support

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* 14. For the A-BOX System that you continue to use. How can it better meet your needs?

A-Box Device

A-BOX Instruments

A-BOX Tray

Innovasis Headquarters Support

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* 15. Todays Date

Date

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* 1. Hospital Name

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* 2. Address

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* 3. Physician Name

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* 4. Patient Gender

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

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* 8. Operation Date and Time

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* 9. Total Operative Time (00:00)

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* 10. How well did the following areas meet your needs?

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* 11. Any other suggestions for possible future improvements?

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* 12. When using the A-BOX System, did the Patient(s) progress as expected?

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* 13. For the A-BOX System that you used briefly, but stopped. Why did you stop using it?

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* 14. For the A-BOX System that you continue to use. How can it better meet your needs?

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* 15. Todays Date

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* 16. Your Name