Sample cover letter centers for disease control and

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(Sample Cover Letter)

Date

Dear (e.g., staff member, healthcare worker, employee): [Name of organization] is conducting a survey to evaluate a device with an engineered sharps injury prevention feature. Your feedback on this product is important in order to identify safer devices that allow us to better serve our workforce. Please complete the attached form, which will only take a few minutes. All of your responses are confidential. Once they are collected, there is no connection between your name and the survey you complete. Your responses will be combined with others in order to determine the acceptability of this new device. If you need help completing this survey or have any questions, please ask _________. When you have completed the survey, please return it to ___________. Thank you in advance for providing this information.

Sample Device Evaluation Form

Product: [Filled in by healthcare facility]

Date: ________________________

Department/Unit: _________________

Position/Title: _________________

1. Number of times you used the device.

1-5

6-10

11-25

26-50

More than 50

2. Please mark the box that best describes your experiences with the device. If a question is not applicable to this device, do not fill in an answer for that question.

Neither

Strongly

Agree nor

Strongly

Disagree Disagree Disagree Agree Agree

Patient/Procedure Considerations

a. Needle penetration is comparable to the standard device.

1

2

3

4

5

b. Patients/residents do not perceive more pain or

discomfort with this device.

1

2

3

4

5

c. Use of the device does not increase the number

of repeat sticks of patient.

1

2

3

4

5

d. The device does not increase the time it takes

to perform the procedure.

1

2

3

4

5

e. Use of the device does not require a change in

procedural technique.

1

2

3

4

5

f. The device is compatible with other equipment

that must be used with it.

1

2

3

4

5

g. The device can be used for the same purposes as

the standard device.

1

2

3

4

5

h. Use of the device is not affected by my hand

size.

1

2

3

4

5

i. Age or size of patient/resident does not affect

use of this device.

1

2

3

4

5

Experience with the Safety Feature

j. The safety feature does not interfere with procedural technique.

1

2

3

4

5

k. The safety feature is easy to activate.

1

2

3

4

5

l. The safety feature does not activate before the

procedure is completed.

1

2

3

4

5

m. Once activated, the safety feature remains engaged.

1

2

3

4

5

n. I did not experience any injury or near miss of

injury with the device.

1

2

3

4

5

Sharps Injury Prevention Workbook: A-13 Sample Device Evaluation Form

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Neither

Strongly

Agree nor

Strongly

Disagree Disagree Disagree Agree Agree

Special Questions about this Particular Device

[To be added by healthcare facility]

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Overall Rating

Overall, this device is effective for both patient/resident care and safety.

1

2

3

4

5

3. Did you participate in training on how to use this product?

No (Go to question 6.)

Yes (Go to next question.)

4. Who provided this instruction? (Check all that apply.)

Product representative

Staff development personnel

Other_______________________

5. Was the training you received adequate? No

Yes

6. Was special training needed in order to use the product effectively?

No

Yes

7. Compared to others of your gender, how would you describe your hand size?

Small

Medium

Large

8. What is your gender?

Female

Male

9. Which of the following do you consider yourself to be?

Left-handed

Right-handed

10. Please add any additional comments below.

THANK YOU FOR COMPLETING THIS SURVEY Please return this form to: ________________________________________________________

Sharps Injury Prevention Workbook: A-13 Sample Device Evaluation Form

Page 2 of 2

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