54 | Annexes
Medical Devices -Touch Controller
2. Medical Device Usability
The purpose of this questionnaire is to identify the aptitude of medical device use (MD) and to check if the
information provided is correct.
This form shall be filled in its entirety for each installed MD by the person (s) responsible (s) of its usage. A copy must
be kept at the ward hospital where the MD has been installed and another must be signed by the person in charge
of the hospital ward and sent back to C.F di Ciro Fiocchetti & C. s.n.c. at one of the following addresses:
e-mail : [email protected]
Fax : +39 0522 976028
If required, the usage of MD can be evaluated according to the following criteria (select only one):
Medical Device Identification
Model
Model Code
Serial number
INTENDED USE
Ward where the MD is installed
Type of stored product
List of Personnel Intended for Use
First Name
Surname
Position
Evaluation
Description
1
Very poor
2
Poor
3
Satisfactory
4
Very good
5
Excellent
