Premier
Syringe Evaluation Form
Page 2
Your Name (optional)
Occupation/Title
Dept/Unit
Today’s Date
Product Name
Key Performance Issues
/Yes/ True
/No/ False
/ Don’t Know/ Not Applicable /1. The syringe functioned satisfactorily for its intended purpose
2. Syringe is suitable for most standard syringe functions
3. What percentage of typical clinical procedures does this product address? / 100% / 75% / 50% / 25% / 0%
4. The product is available in the sizes needed
5. The product is compatible with blunt cannulae
6. The product is compatible with Luer connectors
7. The product is simple to operate
8. The use of this product requires no training
9. The safety feature activated with a one-handed technique
10. The safety feature activated with a two-handed technique
11. The safety feature worked reliably
12. Both hands remain behind the needle during engagement of safety feature
13. The safety feature does not interfere with normal use of this product
14. The product is equally satisfactory for different or diverse patient populations (adults, children, heavy, thin, etc.)?
15. Dosage is clearly visible in test syringe
16. The safety feature could not be bypassed
Feedback
17. Did you experience any needlesticks with the test device? / ¨ Yes / ¨ No18. About how many times did you use the test syringe before you were comfortable using it? (check one)
¨
1 time / ¨
5 times / ¨
10 times / ¨
15 times / ¨
20 times / ¨
I never felt comfortable
19. Did you have any problems with this device?
If yes, please briefly explain below. / ¨ Yes / ¨ No
20. Which device would you rather use: (Please check one)
¨ 1. The product we normally use / ¨ 2. This test one / ¨ 3. Other, please indicate
______
Comments:
Thank you for participating in this product evaluation.
Your input is valuable to our ongoing efforts to reduce bloodborne pathogen exposures.