IV-ARMOR Product Evaluation

We value your opinion

We appreciate your input on the Dale IV-ARMOR^®.

Please answer the following questions:

675 | IV-ARMOR Evaluation Form

Patient

Male

Female

How long was the device left on the patient?

hours

Reason for removal:

Removed IV

72 hours, put on new IV-ARMOR

Restarted IV

Reason for restarting:

Site went bad

Too many occlusion alarms

Other

Did the IV-ARMOR

	Yes	No
Reduce occlusion on IV catheter?
Cover/protect the IV site adequately?
Reduce patient tampering/dislodging?
Reduce patient anxiety/increase comfort?
Prevent need for IV reinsertion?
Increase overall patient’s satisfaction?
Save time?

Any additional comments you would like to add related to the previous section?

Would you recommend the IV-ARMOR for use in your facility?

Yes

No

Please cite any additional comments you may have:

Please cite any additional patient comments:

Contact Information

Salutation

First Name

Last Name

Job Title

Facility

Phone/Mobile

Department

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Please contact me

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