Custom Clinical Evaluation Form - Controlling a Source of Antibiotic-Resistant Organisms

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Clinical Evaluation Form

To create your custom Clinical Evaluation Form, start by entering the following information:

Your Name:		Click here to print the full list of questions. Click here to print a sample of a finished form.
Facility Name:
Unit:
Sage Product #:
Return Form To:

Next, check the boxes next to the questions you would like to have printed on the form. A maximum of 10 questions can be selected. When finished, click "Next Step."

The product instructions are clear and easy to follow.

I like the convenience of the skin antiseptic in a premoistened cloth.

The package provides an appropriate number of cloths for adequate antiseptic body cleansing.

This product is easy to use on body contours and difficult-to-clean areas such as skin folds.

This product saves time over previous methods of antiseptic body cleansing.

There are no drips, runs or pooling when using these cloths.

I believe this product will help improve patient and nursing compliance for antiseptic body cleansing.

This product makes it easier to follow my unit's protocol for antiseptic body cleansing.

The cloths are smooth and comfortable on my patient's skin.

The cloths are warm and soothing on my patients skin.

The ability to warm this product in a microwave is beneficial and saves time.

This product eliminates the need for rinsing, which can reduce the effectiveness of chlorhexidine gluconate (CHG).

In addition to skin antisepsis, the cloths gently yet effectively remove dirt and debris.

The Sage antiseptic formula does not dry out the skin like alcohol-based antiseptic cleansers can.

This product improves skin decolonization efforts at my facility.

This product makes skin decolonization efforts easier at my facility.

This product makes skin decolonization efforts more consistent at my facility.

This product makes skin decolonization efforts easier and more consistent at my facility.

This product is preferred over previous methods of antiseptic body cleansing.

My patient prefers this method of antiseptic body cleansing over previous interventions.

I believe this product is an improvement in the quality of patient care at this facility.

I recommend this product over previous methods of antiseptic body cleansing.

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