Off-Site Bioskills Lab Request Form: North America and International Off-Site Bioskills Lab Request Form: North America and International Off-Site Bioskills Lab Request Form: North America and International Step 1 of 5 20% Off-Site Bioskills Labs Bioskills labs provide surgeons the opportunity to gain hands-on experience with Globus Medical innovative technology in a cadaver lab setting. Labs are led by clinical field specialists and are typically 1 to 2 stations. Requests are made on an as needed basis and are held throughout the year at various locations regionally. Accommodations and travel will not be provided as attendees should be local to the lab facility. Domestic and International programs will be conducted based on the need for training in each country. Academic institutions may also request to have their residents and fellows trained in a cadaver setting with Globus Medical technology. Bioskills labs may be led by the attending surgeons however, funding is only provided to support the essential needs to run the cadaver lab. Bioskills labs support Spine, Imaging, Navigation and Robotics (INR), Cranial, Trauma, Joint Arthroplasty and Algea educational needs. Request Process: 1. Please complete the BioSkills Request Form in its entirety. 2. Upload the required documents listed below: – Facility quote – Equipment Request Form – Specimen quote, if applicable – C-Arm quote, if applicable – Facility contract, if applicable 3. MERC will contact you within 2-3 business days of receipt of all documents. You will receive an automated email with more information once the request has been successfully submitted. Please note:Bioskills labs are approved based on funding and set availability. Incomplete requests will not be processed until all required paperwork is submitted and received. All requests require a minimum of 2 weeks for review and approval. Additionally, MERC/Globus does not replenish disposables that are used from field inventory. Any disposables that come within the education sets is what is available. Please schedule accordingly. Sales Representative Responsibilities: Complete the entire Bioskills lab request form and upload all required documents. Obtain a lab quote from the proposed facility. Work with MERC on program details and identifying needed education sets. Provide an on-site contact who will manage the set-up, workflow, and clean-up of facility. It is required that Globus Medical or Distributor staff is on-site for entirety of event. Sales Representative/Distributor Contact InformationPlease select the location for this Bioskills lab North America International Please select the division for this BioSkills Lab Request Spine Trauma Imaging, Navigation, and Robotics Requestor Name First Last Requestor Email Address Globus Medical Sales Rep/Distributor Name First Last Globus Medical Sales Rep Email Address Is this request a distributor driven training initiative?Yes, I am a distributorNo, I am directPoint of Contact On-Site This person will be responsible for set-up, assisting in the lab and clean-up. The Point of Contact must be physically present for the entire lab from set-up to clean-up.Point of Contact Name First Last Facility InformationName of Facility Hospital/Network Affiliation (if applicable) Facility Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of Facility Contact First Last Name of person who will be the point of contact at the facilityFacility Phone NumberDoes the facility provide specimens? Yes No Please make sure to include this information in the facility quote Does the facility provide C-Arms and C-Arm technicians? Yes No Does the lab require a signed facility contract/agreement? Yes No Lab FocusPlease select the surgical procedure/focus for this lab. If there are multiple procedures, please select one from each drop down.Spine Surgical Procedure 1Advanced Lateral Techniques (ALL Release) ApproachALIFALIF Access and ExposureAnterior Cervical CorpectomyCortical Screws (CentraLIF)Endoscopic Fusion (IntraLIF)KyphoplastyLateral CorpectomyMIS LLIF – Anterior-to-Psoas (ATP) ApproachMIS LLIF – Transpsoas (Direct Look®) ApproachMIS TLIFOpen TLIFOsteotomy Techniques (PSO, SPO, VCR)Posterior Cervical FixationPosterior CorpectomySI Fusion (SI-LOK®)Vertebral AugmentationSpine Surgical Procedure 2Advanced Lateral Techniques (ALL Release) ApproachALIFALIF Access and ExposureAnterior Cervical CorpectomyCortical Screws (CentraLIF)Endoscopic Fusion (IntraLIF)KyphoplastyLateral CorpectomyMIS LLIF – Anterior-to-Psoas (ATP) ApproachMIS LLIF – Transpsoas (Direct Look®) ApproachMIS TLIFOpen TLIFOsteotomy Techniques (PSO, SPO, VCR)Posterior Cervical FixationPosterior CorpectomySI Fusion (SI-LOK®)Vertebral AugmentationTrauma Surgical Procedure 1Distal Radius PlatingFibula PlatingTibial NailingTrochanteric NailingTrauma Surgical Procedure 2Distal Radius PlatingFibula PlatingTibial NailingTrochanteric NailingINR Surgical ProcedureScrew Placement (Open)Screw Placement (Percutaneous)SI Fusion (SI-LOOK®)OtherINR Imaging WorkflowsPlease select one of the three imaging workflows/registration method that you plan to use Intra-OP CT Fluoroscopy Pre-Op CT If other, please list technique(s)Please list the Globus Medical products of interestProposed Number of Lab Stations1234Please provide the number of Surgeon Attendees Are all attendees within travel distance to the lab facility? Yes No Hospital Affiliations for AttendeesPlease provide a brief description of your reasoning for having this lab. Please ensure to include the top learning objectivesIf you are an INR Rep, please confirm you have Brittany Meade, Damon Rossi or Jay Martin’s approval of this event on file, in addition to your Zone Director’s approval. Yes, I have all approvals on file. No, I do not have approvals on file. Event DetailsProposed Event Date MM slash DD slash YYYY Alternative Dates Proposed Event Start Time : Hours Minutes AM PM AM/PM Proposed Event End Time : Hours Minutes AM PM AM/PM Proposed set up date and time? Note: Set arrival may vary due to shipping times.Please list any additional requests or other requirements.INR Approval Yes, I have approval on file No, I do not have approval on file If you are an INR rep, please confirm you have Jay Martin’s approval of this event on file and your Zone Director’s approval on file. Required Documents Please upload the following documents as indicated below. Please note that incomplete requests will not be processed until all required documents are submitted.Facility Quote (must be itemized)Max. file size: 50 MB.Facility Contract (if applicable)Max. file size: 50 MB.Specimen Quote (if not included in facility quote)Max. file size: 50 MB.C-Arm Quote (if not included in facility quote)Max. file size: 50 MB.
