Disposable Eye Protection

Safety Feature Evaluation Form

Date:_________Department:________________Occupation:________________

Product Evaluated:________________________ Number of times used:_________

Please circle the most appropriate answer for each question. A rating of One (1) indicates the highest level of agreement with the statement, five (5) the lowest. Not applicable (N/A) may be used if the question does not apply to this product.

agree............disagree
1. The product allows you to have it with you, or easily accessible to you at all times (fits in pocket, etc.).	1	2	3	4	5	N/A
2. The product does not fog up.	1	2	3	4	5	N/A
3. The product works well for a wide variety of head sizes.	1	2	3	4	5	N/A
4. The product is light weight.	1	2	3	4	5	N/A
5. The product is comfortable to wear for extended periods of time.	1	2	3	4	5	N/A
6. The product does not distort vision.	1	2	3	4	5	N/A
7. The product is shatter proof.	1	2	3	4	5	N/A
8. The product offers splatter protection from all angles.	1	2	3	4	5	N/A
9. The product can be used while wearing prescription glasses or can accomodate prescription lenses.	1	2	3	4	5	N/A
10. The product is easily disposable.	1	2	3	4	5	N/A

TDICT Project

Trauma Foundation Bldg. #1, Rm. #300

San Francisco General Hospital

1001 Potrero Ave

San Francisco, CA 94110

info@tdict.org