BioSkills Lab Request Form (NORTH AMERICA) BioSkills Lab Request Form (NORTH AMERICA) BioSkills Lab Request (North America) Form Step 1 of 5 20% North America BioSkills Lab Request Form and Guidelines Globus Medical’s Bioskills training labs provide practicing orthopaedic and neurological surgeons the opportunity to refine and enhance their skills and techniques through hands-on cadaveric trainings. These labs are led and operated by Globus Medical’s sales personnel, and our focus is to offer attending surgeons an educational experience locally. Bioskills labs are regional labs and no accommodations will be made. Regional labs are labs in which surgeons can drive to and from within the same day. Travel should be less than two hours. Request Process: 1. Please complete the BioSkills Request Form in its entirety. 2. Upload the required documents listed below: – Facility quote – Specimen quote, if not included in facility quote – C-arm quote, if not included in facility quote – 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 request is successfully submitted. Please note: 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 – both funding, and set approval. Additionally, MERC/Globus do 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 entire form and upload all required documents. Obtain quote from proposed facility. Work with MERC on program details and identifying needed 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 InformationRequestor Name First Last Requestor Email Address Globus Medical Sales Rep/Distributor Name First Last Globus Medical Sales Rep Email Address Please select the division for this BioSkills Lab Request Spine Trauma Imaging, Navigation, and Robotics Spine Vice President (Conditional)Brian Gallagher (Pacific Region)Dave Cook (Southeast Region)David Cole (West Region)Patrick Hubbard (South Central Region)Micah Schmitt (Northeast Region)Mike Melchionni (Mid-Atlantic Region)Tyler Burklow (Central Region)Trauma Vice President (Conditional)Eric Sorensen (West Region)Eric Stenslie (Mid-West Region)Jeff Colonna (Northeast Region)Joe Gaynor (NJ/NY Metro Region)John Loew (Mid-Atlantic Region)Steve Wilkin (Southeast Region)Trauma Vice President (Conditional)Chris O'Hara (West)Guy Budinscak (Southeast)Dan Cummings (Northeast)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)What Globus Medical Products will you be requesting?Proposed Number of Lab Stations1234Please provide the number of Surgeon Attendees Hospital Affiliations for AttendeesPlease provide a brief description of your reasoning for having this lab. Please ensure to include the top learning objectivesEvent 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.