Patient and Caregiver
Education and Skills Checklist
Patient
Initials
Caregiver
Initials
Educator
Initials
Comments
Received HVAD® System Patient Manual
Reviewed life style recommendations,
including travel procedures, emergency
preparedness, activity limitations, etc.
Reviewed what constitutes an emergency
and emergency directions, including who
and when to call
HANDS-ON SKILLS CHECKLIST
Review and
Demonstration
Trainee Trainer
Initials
Initials
Successful
Demonstration
Certifier Initials
and Date
POWER SOURCE
State the 3 combinations of power sources (2 batteries, 1 battery and
AC adapter, 1 battery and DC adapter)
Identify the amount of power remaining on a battery
using the Test Button
Identify the amount of power remaining on a battery using the battery
indicator on the controller
Successfully complete power source exchange from AC/DC adapter
to battery
Successfully complete power source exchange from battery to
AC/DC adapters
BATTERY CHARGER
State the meaning of each status light on the battery charger
Identify the power indicator light for the battery charger
Successfully place and remove a battery in and out of a battery slot
CONTROLLER
Identify the four connectors to the controller (2 power supply, 1
driveline and 1 monitor connector)
Identify the controller display, buttons and indicators
(AC/DC indicator, alarm mute button, alarm indicator,
battery indicator #1 & #2, scroll button and controller display)
State purpose and care of driveline cover
Successfully complete a controller exchange
ALARMS
Identify indicators (visual and audible) and actions of
low priority 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
Correctly place controller and batteries within the patient pack
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
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GL1108 Rev01 11/14
Patient and Caregiver
Education and Skills Checklist
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
www.heartware.com/clinicians/intructions-use.
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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GL1108 Rev01 11/14