Date:____________________

Name: ____________________

Position: ____________________

Department: ____________________

Product Tested: ____________________

Testing Date(s): ____________________

To guard against infections and other bloodborne injuries and ensure compliance with OSHA standards and directives, [ Company/FacilityName ] will periodically evaluate new sharps safety devices that come on the market.

Since we value employees' opinions, we may ask you to test a particular safety device and let us know what you think about it before introducing it to general use. When you finish testing the device, please answer the following questions, sign the form and return it [ name of official ].

1. Does the user have to activate the safety device to get it to work?
Yes 
  No

2. If activation is required, can it be done with one hand?
Yes 
  No

3. Is there a visible indication showing that the device has been activated?
Yes 
  No

4. Is the safety device part of the product (like a self-sheathing needle or vacuum tube holder)?
Yes 
  No

5. Does the design of the device prevent improper use?
Yes 
  No

6. Can you use the product without activating the safety device?
Yes 
  No

7. Can the safety device be removed or disabled?
Yes 
  No

8. Does the safety device take longer to use than the devices we use now?
Yes 
  No

9. Is it easy to use the device while wearing gloves?

10. Does the device work with all size needles that we currently use?
Yes 
  No

11. Did the safety device work reliably each time you used it?
Yes 
  No

12. Is the contaminated needle covered after use and before disposal?
Yes 
  No

13. Is the device harder to dispose of than the device you use now?
Yes 
  No

14. Do you think that users will need extensive training to use the device?
Yes 
  No

15. Is the device at least as safe and comfortable for patients as what you use now?
Yes 
  No

16. Do you think this safety device is safer than what you use now?
Yes 
  No

Please indicate if you think we should adopt this safety device for general use and list specific reasons for your conclusion: ____________________________________________________________

____________________________________________________________

____________________________________________________________

Employee Signature:____________________

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