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PMS Survey

PMS SURVEY 
0%
Questions marked with an * are required Exit Survey
 
 
We remind you that a contribution of the distributors is requested in Post-Marketing Surveillance (PMS) process (as defined in the distributor agreement). PMS activity consists of an organized collection of safety and efficacy data for all marketed-products. Therefore, you would have to fill out a PMS Form for each GRAFTYS product family. The PMS form is not exhaustive and may be completed with additional data (upon Graftys request or according to your assessment).
 
 
 
DISTRIBUTION INFORMATION 
 
 
 
* Date of reporting:
MonthDayYear
  
 
 
 
* Reporting Period (year)
   
 
 
* Reporting Perod:
 
Quarter 1
 
Quarter 2
 
Quarter 3
 
Quarter 4

 
 
 
* Distributor Name : 
* Responsable person's Name : 
Address 1 : 
Address 2 : 
City : 
State : 
Zip : 
Phone : 
* Email Address : 
 
 
 
MEDICAL DEVICE INFORMATION
 
 
*
Product family:
 
Graftys injectable technology
 
Graftys BCP technology
 
Graftys TCP technology
 
Graftys BCP technology + Graftys injectable technology
 
 
 
Graftys BCP technology:
 
 
MEDICAL DEVICE INFORMATION
 
 
* Countries of distribution:
   
 
 
Quantity sold for repoting period:
   
 
 
 
POST-MARKETING SURVEILLANCE DATA (FOR REPORTING PERIOD)
 
 
Check and tick the type of collected (or available) data from your Operators, Field sales distributors and Customers (sub distributors and healthcare professional users) about Graftys products and their private labels:
 
*
Post-Marketing clinical study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/Comment:
   
 
 
* Investigational study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Clinical case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Cadaveric case and/or saw bone case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Customer complaint and/or incident/recall?
Customer Complaints, incidents & risk of incidents shall be reported to Graftys with the “Product Complaint Form” as soon as you have been informed of the event (according to the existing legislation and under pain of legal and criminal penalties).
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
 
Graftys injectable technology:
 
 
 
Do you sell the Delivery Gun beside the dose?
 
Yes
 
No
 
 
 
The Delivery Gun:
 
 
 
MEDICAL DEVICE INFORMATION
 
 
* Countries of distribution:
   
 
 
Quantity sold for reporting period:
   
 
 
 
POST-MARKETING SURVEILLANCE DATA (FOR REPORTING PERIOD)
 
 
Check and tick the type of collected (or available) data from your Operators, Field sales distributors and Customers (sub distributors and healthcare professional users) about Graftys products and their private labels:
 
 
* Post-Marketing clinical study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Investigational study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Clinical case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Cadaveric case and/or saw bone case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Customer complaint and/or incident/recall?
Customer Complaints, incidents & risk of incidents shall be reported to Graftys with the “Product Complaint Form” as soon as you have been informed of the event (according to the existing legislation and under pain of legal and criminal penalties).
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
 
Graftys injectable dose:
 
 
 
MEDICAL DEVICE INFORMATION 
 
 
* Countries of distribution:
   
 
 
Quantity sold for reporting period:
   
 
 
 
POST-MARKETING SURVEILLANCE DATA (FOR REPORTING PERIOD)
 
 
Check and tick the type of collected (or available) data from your Operators, Field sales distributors and Customers (sub distributors and healthcare professional users) about Graftys products and their private labels:
 
 
* Post-Marketing clinical study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Investigational study (not sponsored by Graftys)?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Clinical case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Cadaveric case and/or saw bone case?
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
* Customer complaint and/or incident/recall?
Customer Complaints, incidents & risk of incidents shall be reported to Graftys with the “Product Complaint Form” as soon as you have been informed of the event (according to the existing legislation and under pain of legal and criminal penalties).
 
Yes
 
No
 
 
 
Quantity:
   
 
 
Designation/comment:
   
 
 
 
PROMOTIONAL TOOLS RAGARDING GRAFTYS PRODUCTS (not provided by GRAFTYS)
 
 
* Have you obtained approval from GRAFTYS f or all your promotional tools (leaflets, posters, website extracts...)?
 
Yes
 
No
 
NA (if you use ONLY Graftys tools)
 
 
 
Please send us your tools as soon as possible for approval.
 
 
 
* Have you validated all the promotional tools of your own distributors?
 
Yes
 
No
 
NA (if you use ONLY Graftys tools OR if you have not sub-distributors)
 
 
 
Comment:
   
 
 
"Customer Satisfaction Surveys Form" completed?
 
Yes
 
No
 
 
 
CONTACTS
 
 
Do you need any information about PMS ?
Please send your requests to GRAFTYS by Phone or Email:
Phone: +33 (0) 4 42 60 30 00     Email: [email protected]
 
 
 
I, the undersigned, certify that to the best of my knowledge all of the information given in this survey is true and correct.
 
 
 
* First Name : 
* Last Name :