BAPTIST MED CENTER EAST

Name*

First Last

Date*

MM

DD

YYYY

Facility*

Department*

Were you in-serviced?*

Have you used Shower Shield on a patient?*

Was Shower Shield easy to apply and remove?*

Did the Shower Shield keep the dressing dry during showering or sponge bathing?*

Is Shower Shield more effective than the current practice?*

Will Shower Shield save time and promote hygiene?*

Overall, would you recommend the use of Shower Shield?*

Was the patient satisfied with Shower Shield?*

Would you like Shower Shield to be available in your hospital?*

Please Review Your Usage of Shower Shield.*

Additional Comments

Name

This field is for validation purposes and should be left unchanged.

	Yes	No	Indifferent
Were you in-serviced?
Did Shower Shield keep the patient dry?
Did the patient like Shower Shield?
Will you use Shower Shield?
Fifth row

Interested in Shower Shield products?