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Instructions for Using the Sample Device Evaluation Form
Adapting the Forms
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
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.
May, 14 2002
Sample Device Evaluation Form
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