3M™ Cavilon™ No Sting Barrier Film Evaluation Form

Name of Evaluator Title/Role

Facility Name Department
Phone 3M Account Manager
Evaluation Start Date Evaluation End Date

Do you currently use a barrier film in your facility?

 Yes  No  If yes, which brand(s)? ________________________________________

Which size(s) of Cavilon No Sting Barrier Film did you evaluate?

 1mL wipe (code 3344E)  1mL wand (code 3343)  3mL wand (code 3345)
 28mL spray (code 3346E)
For which indications did you use Cavilon No Sting Barrier Film? (tick as many as apply)
 Peri-wound protection  Peri-stomal protection  Skin fold protection
 Peri-tube and device protection  Protection from friction  Protection from adhesives
 Other, please specify ___________________________________

Please compare Cavilon No Sting Barrier Film with your usual barrier film
Much Better Equal To Worse Than Not
Than Applicable
Ease of application    
Effectiveness at protecting skin from damage    
associated with moisture (if applicable)
Effectiveness at protecting skin from damage    
associated with adhesives (if applicable)
Lack of need for removal    
Ability to visualise the skin    
General skin condition following use    
Patient comfort during application    
Ability for tapes and dressings to adhere    
Drying time    
Stickiness/tackiness    
Ease of opening in a sterile manner (if applicable)    
Overall performance    
Additional comments: ________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Would you recommend your facility purchase Cavilon No Sting Barrier Film?

 Definitely  Probably  No If no, please explain ____________________________________

Personal information will be collected by 3M Australia Pty Limited and 3M New Zealand Limited and held in accordance with the 3M Privacy
Policy, details of which may be found on www.3m.com.au and www.3m.co.nz . Personal information will be used to contact you regarding this
evaluation.

3M Australia Pty Limited 3M New Zealand Limited

ABN 90 000 100 096 94 Apollo Drive
Building A, 1 Rivett Road Rosedale
North Ryde, NSW 2113 Auckland 0632 3M and Cavilon are trademarks of 3M Company
Phone 1300 363 878 Freephone 0800 80 81 82 © 3M 2017