TDICT Protective Eyewear Feature Evaluation Web Form

Download the Protective Eyewear Feature Evaluation Form as a PDF
Date
Date Format: MM slash DD slash YYYY
Department
Occupation
Product
Number of times used
This evaluation form should be completed by frontline non-managerial employees who are responsible for direct patient care, cleaning/disinfecting/sterilizing surfaces or devices, and laboratory personnel or anyone at risk of experiencing a splash of blood or body fluid. The completion of this evaluation and review is designed to assist employers with the requirements set forth in the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030(c)(1)(v)).
Please select the most appropriate answer for each question. Not applicable (N/A) may be used if the question does not apply to this particular product.
For the General Consideration of Protective Eyewear:

During Use:

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	NA
1. The product does not fog up when in use.
2. The eyewear is comfortable enough to wear for extended periods of time.
3. The product can be stored in a location that is readily accessible at the point of care/use (e.g., wall mount, caddy, etc.)
4. The eyewear can be dispensed easily from its stored location.
5. The eyewear does not distort vision or visibility.
6. The eyewear is available in prescription offerings or can be used while wearing prescription glasses.
7. The product is available in several sizes, fits, and styles.
8. The product works well with a variety of head sizes and shapes.
9. The product does not slide/slip on the nose or face when looking down, up, or side to side.
10. The product has adequate physical coverage, including side, above, and below the eye.
11. The product is suitable for a variety of types of procedures, patients, and exposure types.

After Use & During Disposal or Reprocessing:

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	NA
12. If disposable, the product can easily be placed in the trash or if contaminated, in a red bag.
13. If reusable, the product can be safely and adequately cleaned and disinfected without compromising its integrity (e.g., fit, vision, visibility).
14. Product manufacturers have provided clear instructions for use, storage, disposal and/or reprocessing.

Of the above questions, which three are most important to your safety when using this product/device?
Are there other questions that you feel should be asked or addressed regarding the safety and utility of this product/device?
TDICT never collects or markets your personal data. Period. How's that for privacy?
Email

Enter the email address of the person who should receive the digital copy of your form response.