**(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]{.underline} Device Evaluation Form**

**Product:** [*\[Filled in by healthcare facility\]*]{.underline}
**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.**

+-----------------------------------+------+------+-------+-----+------+
|                                   | **St | **Di | **Ne  | **A | **   |
|                                   | rong | sagr | ither | gre | Stro |
|                                   | ly** | ee** | Agree | e** | ngly |
|                                   |      |      | nor   |     | Agr  |
|                                   | **Di |      | Disag |     | ee** |
|                                   | sagr |      | ree** |     |      |
|                                   | ee** |      |       |     |      |
+===================================+======+======+=======+=====+======+
| **Patient/Procedure               |      |      |       |     |      |
| Considerations**                  |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| b.  Needle penetration **is**     | 1    | 2    | 3     | 4   | 5    |
|     comparable to the standard    |      |      |       |     |      |
|     device.                       |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| a.  Patients/residents **do not** | 1    | 2    | 3     | 4   | 5    |
|     perceive more pain or         |      |      |       |     |      |
|     discomfort with this device.  |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| b.  Use of the device **does      | 1    | 2    | 3     | 4   | 5    |
|     not** increase the number of  |      |      |       |     |      |
|     repeat sticks of patient.     |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| c.  The device **does not**       | 1    | 2    | 3     | 4   | 5    |
|     increase the time it takes to |      |      |       |     |      |
|     perform the procedure.        |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| d.  Use of the device **does      | 1    | 2    | 3     | 4   | 5    |
|     not** require a change in     |      |      |       |     |      |
|     procedural technique.         |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| e.  The device is compatible with | 1    | 2    | 3     | 4   | 5    |
|     other equipment that must be  |      |      |       |     |      |
|     used with it.                 |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| f.  The device can be used for    | 1    | 2    | 3     | 4   | 5    |
|     the same purposes as the      |      |      |       |     |      |
|     standard device.              |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| g.  Use of the device **is not**  | 1    | 2    | 3     | 4   | 5    |
|     affected by my hand size.     |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| h.  Age or size of                | 1    | 2    | 3     | 4   | 5    |
|     patient/resident **does not** |      |      |       |     |      |
|     affect use of this device.    |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| **Experience with the Safety      |      |      |       |     |      |
| Feature**                         |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| j\. The safety feature **does     | 1    | 2    | 3     | 4   | 5    |
| not** interfere with procedural   |      |      |       |     |      |
| technique.                        |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| k\. The safety feature is easy to | 1    | 2    | 3     | 4   | 5    |
| activate.                         |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| l\. The safety feature **does     | 1    | 2    | 3     | 4   | 5    |
| not** activate before the         |      |      |       |     |      |
| procedure is completed.           |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| m\. Once activated, the safety    | 1    | 2    | 3     | 4   | 5    |
| feature remains engaged.          |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| n\. I **did not** experience any  | 1    | 2    | 3     | 4   | 5    |
| injury or *near miss* of injury   |      |      |       |     |      |
| with the device.                  |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+

+-----------------------------------+------+------+-------+-----+------+
|                                   | **St | **Di | **Ne  | **A | **   |
|                                   | rong | sagr | ither | gre | Stro |
|                                   | ly** | ee** | Agree | e** | ngly |
|                                   |      |      | nor   |     | Agr  |
|                                   | **Di |      | Disag |     | ee** |
|                                   | sagr |      | ree** |     |      |
|                                   | ee** |      |       |     |      |
+===================================+======+======+=======+=====+======+
| **Special Questions about this    |      |      |       |     |      |
| Particular Device**               |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| \[To be added by healthcare       | 1    | 2    | 3     | 4   | 5    |
| facility\]                        |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
|                                   | 1    | 2    | 3     | 4   | 5    |
+-----------------------------------+------+------+-------+-----+------+
|                                   | 1    | 2    | 3     | 4   | 5    |
+-----------------------------------+------+------+-------+-----+------+
| #### Overall Rating               |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+
| Overall, this device is effective | 1    | 2    | 3     | 4   | 5    |
| for both patient/resident care    |      |      |       |     |      |
| and safety.                       |      |      |       |     |      |
+-----------------------------------+------+------+-------+-----+------+

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.**

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## THANK YOU FOR COMPLETING THIS SURVEY

Please return this form to:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_