Request for Assessment or Consultation / Identification of topic to be evaluated
1.-Topic (Description of the technology, clinical condition, and patient type) / 1.-Question (Technology description, pathology or condition and patient type)
2.-The topic is related to / 2.-The question is related to the following domain
Diagnostics
Treatment
Prevention
Organization
3.-Background or description of the current situation
4.-If there is no agreement on indications for use, briefly describe the controversy or uncertainty.
5.-Characteristics of the technology
Is this a procedure...
new (recent appearance or new application of an existing technique)?
used in current clinical practice?
used less frequently?
Approximate frequency of use of the technology (per time unit or per patient)
Alternatives that it replaces or complements
Estimated number of affected patients
Safety of the procedure and patient acceptance
Approximate cost assessment (global, unitary, per act, etc.)
Potential or real impact on organizational, ethical, social, or economic aspects
Applicant’s Name and Family Name
Applicant’s Name and Family Name
Applicant’s Email Address
Applicant’s Email Address
Applicant’s Telephone Number
Applicant’s Telephone Number
Place of Work
Place of Work
Date
I accept
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Please provide references and/or data supporting the arguments.
Please complete one questionnaire per proposed topic. You may also print this form from your browser and send it to the following email: osteba-san@euskadi.eus