Instructions for Using the Sample Screening Form

Adapting the Form
The form can be modified to reflect your specific clinical needs by adding criteria that reflect your practice or deleting criteria that are not appropriate for your practice. For example, if your patient population consists primarily of children, you may choose to add criteria that reflect the use of the device in small mouths.

Completing the Form
It is recommended that an appropriately trained staff person be designated as the safety coordinator for your clinic. In the screening phase, include a representative of each type of dental health care personnel (DHCP) that will be using or handling the device. Be sure that each person completing the form has a sample of the safer device as well as the traditional device in front them.

Interpreting the Results
Once the form has been completed by all DHCP, discuss the results to determine whether to proceed to the next phase – evaluating the safer device in the clinical setting. In making this decision, some criteria may be more important than others. For example, clinical and safety feature considerations may be more important than the general product (e.g., availability of the device) or practical considerations (e.g., instructions and packaging). If the responses to many criteria are “Does Not Meet Expectations” or “No,” then you should consider other safer devices, otherwise, evaluate the device in the clinical setting. 

Sample Screening Form
Dental Safety Syringes and Needles


This form collects the opinions and observations of dental health care personnel (DHCP) who screen a safer dental device to determine its acceptability for use in a clinical setting. This form can be adapted for use with multiple types of devices. Do not use the new device being tested on a patient during this initial screening phase.



Product: Name, brand, company:
Your position or title:
Your occupation or specialty:

Clinical Considerations Does Not Meet Expectations Meets Expectations Exceeds Expectations
1. The device permits the exchange of cartridges during treatment on the same patient. 1 2 3
2. The weight and size of device is acceptable. 1 2 3
3. I have a clear view of the cartridge contents when aspirating. 1 2 3
4. The size and configuration of the syringe or needle permits a clear view of the injection site and needle tip. 1 2 3
5. No excessive force is required to activate or control the plunger. 1 2 3
6. The size and configuration of the syringe or needle permits use in all mouth sizes and access to all areas of the mouth. 1 2 3
7. The device permits multiple injections on the same patient. __No __Yes
8. The device is capable of aspiration before injection. __No __Yes
9. The needle is compatible with a reusable syringe.
[For safety needles without syringes only.]
__No __Yes
10. Does the product meet the needs of your clinical practice based on the above criteria? __No __Yes
11. The worker’s hands can remain behind the sharp during activation of the safety feature. 1 2 3

Safety Feature Considerations

12. The safety feature can be activated with one hand. 1 2 3
13. The safety feature is integrated into the syringe or needle. 1 2 3
14. The safety feature provides a temporary means of protecting the needle between injections. 1 2 3
15. A visible or audible cue provides evidence of safety feature activation. 1 2 3
16. The safety feature is easy to recognize and use. __No __Yes
17. Once activated, the safety feature permanently isolates the needle tip and cannot be purposefully or accidentally deactivated under normal use conditions. __No __Yes
18. The safety feature activates by itself. __No __Yes

General Product/Manufacture Considerations

19. The manufacturer can provide the device in needed quantities. 1 2 3
20. A full range of needle sizes and lengths is available. 1 2 3
21. The company provides free samples for in-use evaluation. 1 2 3
22. The company has a history of responsiveness to problems 1 2 3

Practical Considerations

23. The device is packaged conveniently. 1 2 3
24. The device is easy to remove aseptically from the package. 1 2 3
25. Instructions are included in the packaging. 1 2 3
26. Instructions are easy to follow and complete. 1 2 3
27. Instructions are provided in more than one form (paper, DVD, or online). 1 2 3
28. Use of the safety device will not increase the volume of sharps waste. 1 2 3
29. The shape and size of available sharps containers will accommodate disposal of this device. 1 2 3
30. This is a single use, disposable device. __No __Yes
31. The device should be considered for further clinical evaluation. __No __Yes


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