3M™ Tegaderm™ Transparent Film Dressing
Dialysis Sample Evaluation Form
Name: Date:
Facility: Department:
Facility Address: City/State:
Phone: Zip:
GPO/Distributor: Email address:
1. Check (√) dressing evaluated:
Tegaderm™ Dressing 1616 Tegaderm™ Dressing 1626W Tegaderm™ Dressing 1655
2. Using the scale below, rate the performance of the Tegaderm™ evaluation dressing being evaluated
compared to your current dressing. If you evaluated more than one dressing, please indicate in comment
section.
Please Circle
Performance Factors vs.
Current Dressing
Much Much
Worse Worse Same Better Better
Comments
a. Site Visibility
MW W S B MB
b. Wear Time
MW W S B MB
c. Seal Around Catheter
MW W S B MB
d. Ease of Application
MW W S B MB
e. Ease of Removal
MW W S B MB
f. Patient Comfort
MW W S B MB
g. Overall Performance
MW W S B MB
3. If evaluating the Tegaderm™ dressings 1616 or 1655, rate the value of the following feature(s):
Please Circle
Feature
Not Somewhat Highly Not
Valuable Valuable Valuable Valuable Applicable
Comments
a. Soft Cloth Border
NV SV V HV NA
b. Reinforced Notch
NV SV V HV NA
c. Secural Tape Strips
NV SV V HV NA
4. What dressing do you currently use for hemodialysis catheters? _______________________________
5. What is your current change protocol for hemodialysis catheter dressings? ______________________
6. Would you like to receive additional information (check all that apply):
Rep call
Additional evaluation samples
Purchase product
In Service/product training
7. Listed below are complimentary* 3M Medical products for use in hemodialysis. Please check to receive
additional product information (check all that apply):
3M™ Tempa·DOT™ Thermometers
3M™ Cavilon™ No Sting Barrier Film
Composite/Island Dressings
3M™ Surgical Tapes
3M™ Avagard™ D Instant Hand Antiseptic
Thank you for completing this sample evaluation form. Please send completed form to:
3M Health Care
Attn: Dialysis Direct Mail
912 Industrial Drive
Milbank, SD 57252
or
Fax number: 605-432-9406
May we contact you for future market research purposes? Yes No
May we add you to our email list for future 3M product communications? Yes No
Any contact information you supply will only be used to provide you with information about 3M
products or to send you electronic surveys, and is in accordance with 3M’s privacy policy found at
www.3m.com/privacy.html.
* It is the physician’s obligation to properly report and appropriately reflect any free product on their
submissions to Medicare/Medicaid/private insurance.
3M and Tegaderm are trademarks of 3M.
Printed in U.S.A.
© 3M 2006. All Rights Reserved.
