Samson Medical Technologies

Survey

Please provide the following contact information: Asterisk (*) Denotes Required Field

*Name:
*Title:
*Hospital / Affiliation:
Address:

*City:
*State:
*Zip Code:
*Work Phone:
*Fax:
*Email:
# of Beds, if Hospital:
# of Patients Served, if Home Infusion:
GPO Affiliation:
Contact Person for Purchasing:

If you were able to purchase products in the SmartPak® system containing quantities of products greater than the currently available pharmacy bulk packages, which of the following items would you use?

Please rate the products as follows:
1. Definitely Would Use
2. Would Likely Use
3. May Use
4. Probably Would Not Use
5. Definitely Would Not Use

PRODUCT	RATING
Ampicillin/Sulbactam (Unasyn®)
Cefepime (Maxipime®)
Cefotaxime (Claforan®)
Cefotetan
Cefoxitin
Ceftazidime (Fortaz®/Tazicef®)
Ceftriaxone (Rocephin®)
Clindamycin (Cleocin®)
Famotidine (Pepcid®)
Gentamicin (Garamycin®)
Imipenem/Cilastatin (Primaxin®)
Meropenem (Merrem®)
Nafcillin
Oxacillin
Penicillins (G Potassium or G Sodium)
Piperacillin/ Tazobactam (Zosyn®)
Ranitidine (Zantac®)
Ticarcillin /Clavulanate (Timentin®)
Vancomycin

2. Approximately how many grams or million units of the following products does your institution use?

Please fill in the column that is easiest for you to estimate:
PRODUCT	WEEK	MONTH	YEAR
Ampicillin/Sulbactam (Unasyn®)
Cefazolin (Ancef®)
Cefepime (Maxipime®)
Cefotaxime (Claforan®)
Cefotetan
Cefoxitin
Ceftazidime (Fortaz®/Tazicef®)
Ceftriaxone (Rocephin®)
Cefuroxime (Zinacef®)
Clindamycin (Cleocin®)
Famotidine (Pepcid®)
Gentamicin (Garamycin®)
Imipenem/Cilastatin (Primaxin®)
Meropenem (Merrem®)
Nafcillin
Oxacillin
Penicillins (G Potassium or G Sodium)
Piperacillin/ Tazobactam (Zosyn®)
Ranitidine (Zantac®)
Ticarcillin /Clavulanate (Timentin®)
Vancomycin
Other

3. If the SmartPak® system were available with various amounts of powder/solution, how much powder/solution would you like to see in each bag for the following products?

Please indicate the quantities as follows:

SMALLEST - Least quantity per bag that would be beneficial (e.g., 100 grams Cefazolin) LARGEST - Greatest quantity of powder that you would like to see in one bag (e.g.,300 grams Cefazolin
PRODUCT	SMALLEST QTY	LARGEST QTY
Ampicillin/Sulbactam (Unasyn®)
Cefepime (Maxipime®)
Cefotaxime (Claforan®)
Cefotetan
Cefoxitin
Ceftazidime (Fortaz®/Tazicef®)
Ceftriaxone (Rocephin®)
Clindamycin (Cleocin®)
Famotidine (Pepcid®)
Gentamicin (Garamycin®)
Imipenem/Cilastatin (Primaxin®)
Meropenem (Merrem®)
Nafcillin
Oxacillin
Penicillins (G Potassium or G Sodium)
Piperacillin/ Tazobactam (Zosyn®)
Ranitidine (Zantac®)
Ticarcillin /Clavulanate (Timentin®)
Vancomycin
Please specify

Thank you for your time and assistance!
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