CPW Meeting Request Form

Cadaveric Practice Workshops A Cadaveric Practice Workshop (CPW) provides local surgeons with an opportunity to practice the safe and effective use of Zimmer Biomet devices and instrumentation, in accordance with approved product indications and surgical techniques in an approved laboratory setting using anatomical material. The idea number of participants is 2-4 HCPs, with 1-2 cadaver stations. This practice modality is not a substitute for a ZBI Bioskills event. CPW Contact: Kendra King Email: kendra.king@zimmerbiomet.com Mobile: 574-453-8577

Today's Date*

Requester First & Last Name*

Distributorship*

Territory #*

Requestor Email*

Requester Phone Number*

Cadaveric Practice Workshop: Designated Attendee (DA)

The Designated Attendee (DA) is a representative from the distributorship/territory who understands and executes all requirements and responsibilities associated with a CPW and ZBI standard procedures. The DA will assist in managing the CPW event, as well as attend the event for its entirety.

Designated Attendee*

CPW Designated Attendee (DA) Responsibilities

Before: Work with ZBI to secure approved lab facility and quote. • Work with ZBI to arrange for anatomical material, if not provided by the lab. • Secure and manage all instruments and implants to support the lab. The sales force is responsible for providing all instruments, power equipment, implants and basic lab equipment. • Arrange for sufficient field personnel to be present at lab to support the event. • Arrange for acceptance of shipment of anatomical material and any other materials for the lab. • Confirm all anatomical material has been sent with a serology report, with non-reactive of negative results for hepatitis B and C and HIV. During: • Accept/Return any shipment made to lab facility • Ensure appropriate Sales Rep support for lab: • Set up lab, tear down, and clean up • Serve as scrub tech/technical advisor • Some facilities may require their own waiver in addition to ZBI’s waiver – It is the DA’s responsibility to complete all necessary paperwork and confirm all participants have been registered in Cvent. • Confirm all anatomical material includes serology report, with non-reactive or negative results for HIV, Hepatitis B&C before usage. After: • Ensure the ZBI workshop waiver, serology testing result, and completed workshop evaluation are signed by everyone in attendance at the event and returned to ZBI at kendra.king@zimmerbiomet.com within 3 business days of event completion. • Arrange for cleaning of instrumentation and appropriate disposal of biomedical waste. Helpful Information for CPW’s and Related Courses Instrument/Implant Guide • The sales force is responsible for providing all instruments and implants • Cleaning and sterilization of instrument is the responsibility of the field Please Note: The field cannot pay an HCP entity to provide this cleaning/sterilization service. Please contact ZBI for guidance.

DA's Email Address*

List of Attendees*

Will this be at the Zimmer Biomet Institute Lab?*

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Select which Zimmer Biomet Institute Lab?*

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Facility*

Must currently be on the approved ZBI facility list, unless it is pro bono.

Has the facility confirmed the date?*

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Address of Event*

City*

State*

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Segment*

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Hip Product*

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Knee Product*

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Foot and Ankle Product*

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Trauma Product*

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Sports Medicine Product*

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Shoulder Products*

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Other Non-Pillar Related Product*

Acknowledgment*

By checking this box you are confirming that by selecting a product above this is NOT a request for product to be sent. You are accepting responsibility for supplying instruments and implants for this lab.

Is this CPW for residents and fellows?*

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Event Information

Event Date*

Start and End Times*

Type*

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Estimated # of HCPS*

HCPs attending

Would you like to use Virtual Reality (VR)?*

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ACKNOWLEDGEMENTS AND AUTHORIZATIONS

*I understand that as the DA, it is my responsibility to follow all Zimmer Biomet Institute DA Responsibilities for CPWs. * I understand that if I need the ZBI to order tissue, I will complete the Tissue Request Form. * I understand the lab and tissue invoices will be paid by the ZBI and charged back at 100% to the distributor (unless you indicated that this is a 10 Commitments Event). * I understand that NO proctor can attend a Cadaveric Practice Workshop. * I understand that instruments/implants are not provided by the ZBI for CPW events. * I understand this is a distributor sponsored event, therefore Save the Dates will NOT be provided by the Zimmer Biomet Institute. * I understand that by submitting this request to ZBI, I am acknowledging that my distributor is aware of this event, and will incur all costs associated with this event. By clicking “FINISH” this form will automatically be submitted via email to the Zimmer Biomet Institute specialist. Thank you.

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