Sample Survey of Device Use for Sharps Injury Prevention Program

As part of a facility's sharps injury prevention program, it is valuable to help product evaluation teams or committees determine how devices are used in their healthcare organization.


Included in the Centers for Disease Control and Prevention's "Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program" is a form for the surveying of device use. The information from this survey helps product evaluation teams identify the device-specific is­sues they must consider when selecting substitute products. Department heads, nursing units or their designees should complete this form.


To download this CDC-developed survey of device use, which includes a sample cover memo, for adaptation and use in your facility, click here (pdf). The example uses a hypodermic needle/syringe. The form will need slight modification if used for other types of devices, but the questions will be similar, if not the same.


Download other patient safety-related tools and resources:


- Sample Surgical Wound Classification Form


- Sample Hand Hygiene Observation Record


- Sample MRSA Policy

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