Facility Assessment

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CaseTrak360 Facility Assessment Questionnaire

Facility Name(*)

Invalid Input

Facility Zip-code (so we can assign it to a representative)(*)

Invalid Input

Rep Name (If you are workig with one of our reps)

Invalid Input

Your Name(*)

Invalid Input

Job Title(*)

Invalid Input

SPD Admin

Number of Workstations

Invalid Input

OR Admin

Number of Workstations

Invalid Input

Decontamination

Number of Workstations

Invalid Input

Prep & Pack

Number of Workstations

Invalid Input

Sterilization

Number of Workstations

Invalid Input

Storage

Number of Workstations

Invalid Input

Case Cart Staging

Number of Workstations

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OR

Number of Workstations

Invalid Input

Workstations Total Number Required

Invalid Input

Cases Per Month

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Number of OR Rooms

Invalid Input

CS Shifts per day and week

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Survey Questions

Have you used a Tracking System before?

YesNo Invalid Input

If yes, which tracking system have you used?(*)

Invalid Input

Does your OR team plan to use CaseTrak360?

YesNo Invalid Input

Do you plan to use the software for Inventory Management?

YesNo Invalid Input

Do you have more than one stock location?

YesNo Invalid Input

Do you have count sheets in electronic format?

YesNo Invalid Input

Do you have preference cards in electronic format?

YesNo Invalid Input

Do you plan to track peel packs?

YesNo Invalid Input

Is it important to link surgical sets to scheduled proceedures?

YesNo Invalid Input

Do you plan to track loaners?

YesNo Invalid Input

Do you plan to track Individual items?

YesNo Invalid Input

Do you plan to track Endoscopes?

YesNo Invalid Input

Select Package Level

Basic - ASC's, clinics, small community hospital. Up To 5 ORs. 10 Total Workstations.

Standard - SPD Modules ONLY. 20 Total Workstations.

Premium - All Inclusive. 20 Total Workstations

Additional Workstations Required

Loaner Module

Endo Module

Item Module

Tissue Module

Invalid Input

Number Of Addtional Workstations

Invalid Input

(*)

Invalid Input

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