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Clinician Feedback Form
NOTE: This feedback form is not meant to be used to report adverse events. To report an adverse event, send an email to
report@maskson.org
.
Please provide feedback about your MasksOn.org Face Shield Kit below.
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MasksOn.org Face Shield Kit
What is your role?
*
MD / DO
RN / LPN
PA / NP
CNA
Fire / EMS
Public Safety
Administration
Other:
Please tell us more about your experience ordering and receiving your Face Shield Kit
1 for Strongly Disagree & 5 for Strongly Agree
Ordering process was clear and easy
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I received my kit(s) quickly
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
The kit being free was a significant factor in me ordering it
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Instructions and warnings were clear
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Instructions answered all my questions
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Have you used the face shield in a clinical setting?
*
Yes
No
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