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Instructions for Using the Sample Device Evaluation Form

Adapting the Form
Like the screening form, the device evaluation form can be modified to reflect your clinical needs by adding criteria that reflect your practice or by deleting criteria that are less relevant to your practice.

Obtaining Feedback
Select staff who represent the scope of personnel who will use or handle the device. Choose a reasonable testing period − 2 to 4 weeks should be sufficient. Staff should receive training in the correct use of the device, which can often be provided by product representatives. Encourage staff to provide informal feedback during the evaluation period. Monitor the pilot test to ensure proper use of the safer device and remove the device immediately if it is found to be unsafe. Forms should be completed and returned to the safety coordinator as soon as possible after the evaluation period.

Interpreting the Results
After the evaluation phase, speak with personnel who have completed the forms to determine the criteria that should receive the most consideration. For example, personnel may express that criteria regarding the "feel" of the device (e.g., weight and size of the device, how the device fits in their hand) are important in maintaining proper injection technique. If the responses to many of the criteria are "Strongly Disagree" or "Disagree," check with personnel who have completed the form to obtain additional information. Balance this feedback with safety and practical considerations before determining whether to continue using the device in your practice.


Sample Device Evaluation Form 
Dental Safety Syringes and Needles

This form collects opinions and observations from dental healthcare personnel who have pilot tested a safer dental device. This form can be adapted for use with multiple types of safer devices. Do not use this form to collect injury data because it cannot ensure confidentiality.


Product: Name, brand, company:
Number of times used:
Your position or title:
Your occupation or specialty:



  1. Did you receive training in how to use this product?
    __Yes [Go to Next Question] __No [Go to Question 4]

  2. Who provided this instruction? (Check All that Apply.)
    __Product representative __Staff member __Other

  3. Was the training you received adequate?
    __Yes __No

  4. Compared to others of your sex, how would you describe your hand size?
    __Small __Medium __Large

  5. What is your sex? __Female __Male



During the Pilot Test of this Device... Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
6. The weight of the device was similar to that of a conventional dental syringe. 1 2 3 4 5
7. The device felt stable during assembly, use and disassembly. 1 2 3 4 5
8. The device fit my hand comfortably. 1 2 3 4 5
9. The anesthetic cartridges were easy to change. 1 2 3 4 5
10. Aspiration of blood into the anesthetic cartridge was clearly visible. 1 2 3 4 5
11. I had a clear view of the injection site and needle tip. 1 2 3 4 5
12. The device did not appear to increase patient discomfort. 1 2 3 4 5
13. The device performed reliably. 1 2 3 4 5
14. I was able to give injections I all mouth sizes and all areas of the mouth. 1 2 3 4 5
15. I used the device for all of the same purposes for which I used the conventional device. 1 2 3 4 5
16. Activating the safety feature was easy. 1 2 3 4 5
17. The safety feature was easy to recognize and use. 1 2 3 4 5
18. The safety feature did not activate inadvertently, causing me to use additional syringes or needles. 1 2 3 4 5
19. The safety feature functioned as intended 1 2 3 4 5
20. The instructions were easy to follow and complete. 1 2 3 4 5
21. I could have used this product correctly without special training. 1 2 3 4 5
22. The "feel" of the device did not cause me to change my technique. 1 2 3 4 5
23. This device meets my clinical needs. 1 2 3 4 5
24. This device is sage for clinical use. 1 2 3 4 5





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