Evaluator title (ex: RN, SLP, OT etc.)

Hospital/Organization

1. Did the FreeArm meet your clinical needs?

2. Who is your patient population?

3. What were you using prior to the FreeArm?

4. How is the FreeArm more effective than what you are currently using to treat your patients?

5. Who/what team at your facility educates patients/families on home tube feeding prior to discharge?

6. Does the FreeArm require education or in-service in addition to the instructional video provided by FreeArm?

7. Overall, how likely are you to recommend the FreeArm for inpatient use?

(Scale 1-10, 10 highly likely and 1 not at all)

8. Overall, how likely are you to recommend the FreeArm for home use?

(Scale of 1-10, 10 highly likely and 1 not at all)

9. Would you recommend this product for use in additional areas of the hospital?

If yes, please explain:

Impact on patient outcomes:

Please select the appropriate rating

Provides a more standardized way to tube feed

Improves comfort/confidence for patients and families

Increases ability to perform therapies while feeding or venting

Addresses/reduces risks to patient safety

Impact on staff productivity and satisfaction:

Please select the appropriate rating

Improves comfort/satisfaction

Decreases steps/streamlines processes/workflows

Decreases tube feeding and/or medication spills

General Comments/Opinions:

Opportunities for Improvement:

Leadership Only:

1. Anticipated number used per year?

2. Will you be sending the FreeArm home with patients and families at discharge?

3. Do you have funds currently available for purchasing?

4. What is your timeframe for purchasing?

5 a. How many FreeArms would you like to be invoiced for purchase?

5 b. How many Clips would you like to be invoiced for purchase?

FreeArm Evaluation Survey