Education and Skills Checklist

Patient and Caregiver Ongoing

Education and Skills Checklist

Patient Initials / Caregiver Initials / Educator Initials / Comments
Reviewedlife style recommendations, including travel procedures, emergency preparedness, activity limitations, etc.
Reviewed what constitutes an emergency and emergency directions, including who and when to call
Review warnings and precautions and abnormal equipment behavior
HANDS-ON SKILLS CHECKLIST / Review and Demonstration / Successful Demonstration
Trainee Initials / Trainer Initials / Certifier Initials and Date
POWER SOURCE
Accurately demonstrates ability to change power sources and respond to low priority alarms
BATTERY CHARGER
State the meaning of each status light on the battery charger
Identify the power indicator light for the battery charger
CONTROLLER
Successfully complete a controller exchange
ALARMS
Identify indicators (visual and audible) and actions of medium priority alarms
Identify indicators (visual and audible) and actions of high priority alarms
Identify audible indicator and actions of “no power” alarm
Identify silencing of alarms
ACCESSORY PACKS
Successfully place controller and batteries in the shower bag
DRIVELINE EXIT SITE CARE
State the signs and symptoms of driveline exit site infection
Successfully demonstrate driveline exit site care
OTHER

My signature below indicates that I have completed the above listed requirements for hands-on training certification of the HVAD® System and that all my questions have been answered to my satisfaction.

______

(Patient/Care Giver signature)(Date)

My signature below indicates that the patient/care giver has successfully completed the above listed requirements for hands-on training certification of the HVAD® System.

______

(Certifier signature)(Date)

WARNING: Serious and life-threatening adverse events, including stroke, have been associated with use of this device. A user must fully consider the risks of this device with that of other treatment modalities before deciding to proceed with device implantation.
For full prescribing information please see the Instructions for Use (IFU). The IFU can be found at
In the USA the HVAD system is intended for use as a bridge to cardiac transplantation in patients who are at risk of death from refractory end-stage left ventricular heart failure.
CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. Refer to the “Instructions for Use” for complete indications for Use, Contraindications, Warnings, Precautions, Adverse Events and Instructions prior to using this device. /

This Form has been provided by HeartWare for general informational purposes. The list of items on the Form is not intended to be an exhaustive list. The Form is not intended to constitute medical advice, nor should it be used as a replacement for the advice, treatment or diagnosis of a licensed physician. Only a licensed physician may make the decision to discharge a patient. Satisfactory completion of this Form does not qualify a patient for discharge, nor should such completion be used as a replacement for the evaluation or decision of a licensed physician. If you have questions related to the Form, you may contact your HeartWare representative. In addition, HeartWare Clinical Support is available via the Emergency Hotline (888.494.6365). This Hotline resource is available 24 hours a day, 7 days a week, 365 days a year.

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GL1109 Rev01 11/14