ࡱ>  \bjbj ËË  nnnnn8lg 4$*-Z/z||||||$n1**"11nn0 !4441Fnnz41z44LzP ]2<1Zf70g\y2`yzynz60>t0,40$0606060(4606060g1111y606060606060606060 4:  FORM A: TECHNOLOGY REQUEST To be completed by Applicant Name of Applicant:  FORMTEXT      (Office use only) EDSP ID:  FORMTEXT      Department:  FORMTEXT      Division:  FORMTEXT      Phone:  FORMTEXT      Email:  FORMTEXT       Pager:  FORMTEXT      A-1. Name of proposed technology (or trade name if applicable):  FORMTEXT       This application will be assessed using Appendix III: Criteria for Technology Assessment. A-2. Product Manufacturer: FORMTEXT      Distributor: FORMTEXT        FORMCHECKBOX N/A A-3. Type of proposed technology:  FORMCHECKBOX  Device  FORMCHECKBOX  Process of Care  FORMCHECKBOX  Medication A-4. Category of proposed technology: [Check ALL that apply]  FORMCHECKBOX  Innovative/Experimental New Little or no safety and effectiveness data is available AND/OR not presently an insured service AND/OR not approved by Health Canada.  FORMCHECKBOX  Proven New Clinical safety and effectiveness have been demonstrated, but technology has not been used in the local environment AND/OR is not presently an insured service in 鶹ӳ.  FORMCHECKBOX  Replacement of Existing Technology The old version is discarded and proposed version is adopted.  FORMCHECKBOX  Upgrade or addition of Existing Technology New features are added to existing technology.  FORMCHECKBOX  Discard A-5. Request for:  FORMCHECKBOX  Permanent use Estimate the number of patients/devices/procedures per year:  FORMTEXT        FORMCHECKBOX  Testing a limited number Estimate the number of devices or patients that will be tested:  FORMTEXT        FORMCHECKBOX  One-Off, Urgent/Emergent Request. For use on a single patient. Health Gain A-6. Efficacy. Briefly describe the proposed technology including: a) its important features:  FORMTEXT       b) patient characteristics and indications for use:  FORMTEXT       c) its advantages and health benefits (clinical outcomes and/or QoL) over current practice:  FORMTEXT       d) if this is a replacement, upgrade, addition, or discard of an existing technology as checked in #A-4, describe the existing technology (comparison product) and the reason(s) for change:  FORMTEXT       e) if this benefits cases with few alternatives (One-Off Urgent/Emergent Request as checked in #A-5), describe the circumstances:  FORMTEXT       Service Delivery A-7. Safety a) Please indicate the safety category:  FORMCHECKBOX  Risk Profile is the same as comparator procedure(s). A comparator procedure may be the current  gold standard procedure or Best Practice, an alternative procedure, a non-surgical procedure or no treatment (natural history). please describe:  FORMTEXT        FORMCHECKBOX  Risk Profile is different from comparator procedure: please describe:  FORMTEXT        FORMCHECKBOX  Risk Profile is Unknown. Safety has not been determined. b) Is there known or potential contraindications, product warnings, or risks to: Patients:  FORMCHECKBOX 8rt±{gUC.)jhehWYB*CJU\aJph#hehWY5B*CJ\aJph#heh}+5B*CJ\aJph&hehWY56B*CJ\aJph+jheh#2CJU\aJmHnHu&jhehSr;CJU\aJheh#2CJ\aJ jheh#2CJU\aJhehWY5CJ\aJh'CJ\aJ#h'56CJOJQJ\^JaJ h'\h'CJOJQJ\^JaJ8rt " b Hykd$$Ifl0d'h t044 layte $IfgdL /$$d%d&d'd-DM NOPQa$$a$     : < P R T ^ ` v x §•vjVv@vvj+jhehWYCJU\aJmHnHu&jvhehWYCJU\aJhehWYCJ\aJ jhehWYCJU\aJhehWY5CJ\aJ#hehWY5B*CJ\aJph4jhehWYB*CJU\aJmHnHphu)jhehWYB*CJU\aJph/jxhehWYB*CJU\aJph hehWYB*CJ\aJph   4 6 8 B D H T ۷ۜ۷ۜt۷ۜ`۷Rheh_5CJ\aJ&jhehWYCJU\aJ&jVhehWYCJU\aJ&jfhehWYCJU\aJhehWYCJ\aJhehWY5>*CJ\aJhehWY5CJ\aJ+jhehWYCJU\aJmHnHu jhehWYCJU\aJ&jhehWYCJU\aJb  F ikd$$IflF d'h h h t0    44 layte $IfgdL F H | $IfgdL ykdF$$Ifl0d'h t044 layteT \ ^ F ի򢖢|k_Kk&jhehfCJU\aJhehfCJ\aJ jhehfCJU\aJhehf5CJ\aJh'5>*CJ\aJh'56CJ\aJh'CJ\aJ+jhehL CJU\aJmHnHu&jhehL CJU\aJ jhehL CJU\aJhehL CJ\aJhehL 5CJ\aJ N x $Ifgdf$a$hkdD$$IflM'8( t044 layte   " $ 8 : < F H L N P l n p z | ʻ}kVkK@h'5CJ\aJhf5CJ\aJ)jhehf5CJU\aJ#jhehf5CJU\aJhehf>*CJaJ(jhehfCJUaJmHnHu#j8hehfCJUaJhehfCJaJjhehfCJUaJhehf5CJ\aJ jhehfCJU\aJ+jhehfCJU\aJmHnHux z | z | *{wwndW 5^5`gdf 5^5`8^8gdf d^gdfzkd&$$Ifl \X#'X, t44 layte    @ B ^ ` b    *y{|壕{f[hf5CJ\aJ)jq hkSVh'5CJU\aJhfCJ\aJ jh/UCJU\aJjh'CJU\aJh'CJ\aJ#jh'5CJU\aJ#jh'5CJU\aJ)jh!hR5CJU\aJh'5CJ\aJjh'5CJU\aJ#Z68:XвНВЀxofoU jh!h'CJU\aJh#25CJaJh'5CJaJh'CJaJ#jI h'5CJU\aJh;5CJ\aJ)j h!hR5CJU\aJ)j] hkSVh'5CJU\aJh'CJ\aJh'5CJ\aJjh'5CJU\aJ)j hkSVh'5CJU\aJ{ZXP>48d^8`gdr` 0d^`0^gdf8^8gdf d^gdf 5^5`gdf 5^5`P³pZH:h;h'5CJ\aJ#jh;h'5CJU\aJ+jh!h'CJU\aJmHnHu&j h!h'CJU\aJh#2CJ\aJh'CJ\aJ#j7 h'5CJU\aJh'5CJ\aJjh'5CJU\aJh'5>*CJ\aJ jh!h'CJU\aJ&j h!h'CJU\aJh!h'CJ\aJ$&*,\^`>ʼʮүʈٴڰڱʰҰ<h'>*CJ\aJh'CJ\aJh;5CJ\aJh'5>*CJaJh'Bh'5>*CJaJh'5CJaJh'5CJ\aJh;h'CJ\aJh;h]ACJ\aJh;h]A5CJ\aJh;h|m5CJ\aJh;h ?5CJ\aJh;h'5CJ\aJ#jh;h'5CJU\aJ)j% h[hR5CJU\aJprvxz  "$&ïϙώzi]Ii&jh!hSr;CJU\aJh!h#2CJ\aJ jh!h#2CJU\aJhL CJ\aJh'5CJ\aJh'>*CJ\aJ+jh!h'CJU\aJmHnHu&j h!h'CJU\aJh!h'CJ\aJ jh!h'CJU\aJh'CJ\aJhL hL CJ\aJhL >*CJ\aJ&0248:BV`~ 8NR`dt~fʿuaآ&jh!hSr;CJU\aJh!h#2CJ\aJhL CJ\aJhdh'56CJ\aJh[CJ\aJh'>*CJ\aJh'CJ\aJh#2CJ\aJh'5CJ\aJh#2h'5>*CJaJ jh!h#2CJU\aJ+jh!h#2CJU\aJmHnHu"f (*`̺ץיsg[gOFs=h'CJ\aJh[CJ\aJhh;CJ\aJhh ?CJ\aJhh|mCJ\aJhh'CJ\aJhh#2CJ\aJhh'5CJ\aJh'5>*CJ\aJ(jh!h'CJUaJmHnHu#jh!h'CJUaJh!h'CJaJjh!h'CJUaJhL CJ\aJ h;h'56>*CJ\aJ2 "L 8d^8gdVgR d^gd#2 8^8`d^`gd:d^`gd:J  ^gd#20dh^`0gd:J 0^`0gd_8d^8`gd#2028ﰧynbVH?h'5CJaJjh'5CJUaJh:Jh'CJ\aJh:Jh:JCJ\aJh.G5CJ\aJh'Bh;5CJ\aJh'5CJ\aJh'5>*CJ\aJh_CJ\aJh#2CJ\aJh'CJ\aJ+jh!h'CJU\aJmHnHu&j{h!h'CJU\aJh!h'CJ\aJ jh!h'CJU\aJfhϺq^P?P jh'B5CJUaJjh'B5CJUaJ%jh[5CJUaJmHnHu&jih:h[5CJUaJjh[5CJUaJh[5CJaJh:h[CJaJh[h[CJaJh'CJaJh'5CJaJh:h'B5CJaJh'B5CJaJh:J5CJaJjh'5CJUaJ jh'5CJUaJ<`bdxz| "(:ݶݭ|tl`WKBh'CJ\aJh:Jh'CJ\aJhVgRCJ\aJh:Jh:JCJ\aJh:JCJaJh'CJaJh'5CJaJh.G5CJaJ jh'B5CJUaJjh'B5CJUaJh'B5CJaJ%jh:5CJUaJmHnHu&jWh:hr5CJUaJjh:5CJUaJh:h:CJaJh:5CJaJLLLLL.L0L2L:L@LnLpLLLLLLLLLƻƻƻƻymYyCy+jh!hVgRCJU\aJmHnHu&j1h!hVgRCJU\aJh!hVgRCJ\aJ jh!hVgRCJU\aJhVgR5CJ\aJ#jhVgR5CJU\aJ#jEhVgR5CJU\aJUhVgR5CJ\aJjhVgR5CJU\aJh=CJ\aJhVgRCJ\aJh_hVgR5CJ\aJh=5CJ\aJ No  FORMCHECKBOX  Yes If  Yes , please list?  FORMTEXT       Health care practitioners:  FORMCHECKBOX  No  FORMCHECKBOX  Yes If  Yes , please list?  FORMTEXT       A-8. Users Please list additional potential users (other Divisions or Departments) that may use this technology:  FORMTEXT       A-9. Training a) Please estimate how many health care practitioners already have the expertise to use this technology? FORMTEXT       b) Will additional training be required to operate the technology?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If  Yes , please estimate who and how many will require training?  FORMCHECKBOX  Physicians  FORMTEXT        FORMCHECKBOX  Nurses  FORMTEXT        FORMCHECKBOX  Others  FORMTEXT       A-10. Location Proposed location for use:Service(s): FORMTEXT      Site(s): FORMTEXT       A-11. Change from current practice: [See Appendix I: Technology Assessment Screening Guide] Please indicate if this technology represents a:  FORMCHECKBOX  Minor change from current practice.  FORMCHECKBOX  Significant change from current practice. A-12. Type of review requested (See, Overview of Evaluation Pathways):  FORMCHECKBOX  Technology Request. (Minor change from current practice or simple vendor change.)  FORMCHECKBOX  Expedited Local HTA. Additional information may be needed from the Applicant.  FORMCHECKBOX  Full Local HTA. Additional Clinical information (Form E) may be required from Applicant.  FORMCHECKBOX  One-Off, Urgent/Emergent Request. Benefits cases with few alternatives. Submit directly to Local HTA Committee; [see Appendix VIII: One-Off, Urgent/Emergent Evaluation Process]  FORMCHECKBOX  Don t know. Applicant Signature:  FORMTEXT      Date:  FORMTEXT       (signature and pdf file submission is recommended)  Submit completed Form A and accompanying Form B to Division Chief or Department Head for support.      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