Form 4598-67E "Pap Device Evaluation Form - Assistive Devices Program (Adp)" - Ontario, Canada

Form 4598-67E or the "Pap Device Evaluation Form - Assistive Devices Program (adp)" is a form issued by the Ontario Ministry of Health and Long-term Care.

Download a PDF version of the Form 4598-67E down below or find it on the Ontario Ministry of Health and Long-term Care Forms website.

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Download Form 4598-67E "Pap Device Evaluation Form - Assistive Devices Program (Adp)" - Ontario, Canada

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PAP Device Evaluation Form
Ministry of Health
and Long-Term Care
Assistive Devices Program (ADP)
5700 Yonge Street, 7
Floor
th
Toronto ON M2M 4K5
Section 1 – ADP Registered Sleep Clinic Information
Clinic Name
Clinic Number
Contact Person
Business Telephone Number
Email Address
ext.
Section 2 – Evaluator Information
Start Date of Product Evaluation (yyyy/mm/dd)
End Date of Product Evaluation (yyyy/mm/dd)
Evaluator Name
Professional Title
Evaluator Name
Professional Title
Section 3 – Positive Airway Pressure Device Information
Manufacturer
Description of Device (Make and Model)
Manufacturer Contact Person
Business Telephone Number
ext.
Section 4 – Evaluation: Clinical Assessment
Please answer the following questions
Describe the protocol used to clinically evaluate the equipment
Identify the conditions which would require the use of this device
Describe the effectiveness of this device in treating the conditions listed above
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
Comments or recommendations to the manufacturer
4598-67E (2015/11)
© Queen's Printer for Ontario, 2015
Disponible en français
Page 1 of 4
PAP Device Evaluation Form
Ministry of Health
and Long-Term Care
Assistive Devices Program (ADP)
5700 Yonge Street, 7
Floor
th
Toronto ON M2M 4K5
Section 1 – ADP Registered Sleep Clinic Information
Clinic Name
Clinic Number
Contact Person
Business Telephone Number
Email Address
ext.
Section 2 – Evaluator Information
Start Date of Product Evaluation (yyyy/mm/dd)
End Date of Product Evaluation (yyyy/mm/dd)
Evaluator Name
Professional Title
Evaluator Name
Professional Title
Section 3 – Positive Airway Pressure Device Information
Manufacturer
Description of Device (Make and Model)
Manufacturer Contact Person
Business Telephone Number
ext.
Section 4 – Evaluation: Clinical Assessment
Please answer the following questions
Describe the protocol used to clinically evaluate the equipment
Identify the conditions which would require the use of this device
Describe the effectiveness of this device in treating the conditions listed above
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
Comments or recommendations to the manufacturer
4598-67E (2015/11)
© Queen's Printer for Ontario, 2015
Disponible en français
Page 1 of 4
Section 5 – Evaluation: Performance/Safety
Is the on/off selection switch easily accessible to the user?
Yes
No
If no, please explain
Is the pressure selection switch (if applicable) easily accessible to the user?
Yes
No
If yes, how does the manufacturer address this issue?
Are there any sharp edges/protrusions?
Yes
No
If yes, please explain
Are valves (if applicable) designed to be assembled in one manner only?
Yes
No
If no, please explain
Is the pressure range acceptable?
Yes
No
If no, please explain
Does the device deliver the specified pressure and flow?
Yes
No
If no, please explain
Comments and recommendations to the Manufacturer
4598-67E (2015/11)
Page 2 of 4
Section 6 – Evaluation: Durability/Reliability
CPAP/APAP/BPAP Pressure Blower
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Nasal Mask
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Headgear
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Corrugated Tubing
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Pressure/Non-rebreathing
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Pressure Adapters/Oxygen Entrainment
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
4598-67E (2015/11)
Page 3 of 4
Other
Rate the client response to this device using the following scale:
1 (poor) to 10 (excellent)
1
2
3
4
5
6
7
8
9
10
If any response was scored below 5, please explain
Did anything break or malfunction during the evaluation period?
Yes
No
If yes, please specify what failed and the circumstances in which the failure occurred
Comments and recommendations to the Manufacturer
Section 7 – Conclusion
The device would meet the needs of your patients.
Yes
No
Does this unit compare in cost to existing technology?
Yes
No
Comments
Identify advances in technology present in this device
Describe the advantages as they relate to the patient/client
Equivalent Purpose Devices
Name of equivalent
Price of equivalent (if available)
Evaluator Information
Name of evaluator
Title
Signature
Date (yyyy/mm/dd)
This form is intended to identify potential products for ADP funding. It does not constitute an endorsement of the product.
Please return the completed form to: Assistive Devices Program, 5700 Yonge St., 7
th
Floor, Toronto ON M2M 4K5.
Attention: Program Coordinator, Respiratory Devices.
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4598-67E (2015/11)
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