Feedback Survey for the Disposable LACLS
This survey form is designed for feedback from professional health care therapists and administrators regarding satisfaction with the Disposable LACLS (LACLS[D]) for screening of functional cognitive capacities with individuals for whom infection control procedures must be observed. The LACLS[D] is intended for single or serial use with an individual, after which it should be discarded.

We respect your confidentiality. We will make certain that your responses are kept confidential and that survey results do not contain information that might personally identify you.

After you have used the Disposable LACLS tool with one or more clients (the clients do not have to be persons with infection control needs), please complete the following questions which should take less than 5 minutes. Please only respond one time to this survey. Thank you for your feedback.

Feedback Questions
Please select ONE response for each feedback item 1-9 below.
1. Overall, how satisfied or dissatisfied are you with the Disposable LACLS for use in infection control?
2. How effective is the Disposable LACLS for meeting infection control requirements in your setting?
3. How acceptable is the time needed to set up the Disposable LACLS for single or serial use with each client?
4. How confident are you that use of only the large version of the Disposable LACLS meets your needs for screening of functional cognitive capacities with your client population?
5. How well does use of the leather lace without needles work for making the whip and single cordovan stitches with your client population?
6. How would you rate the value for the money of the Disposable LACLS?
7. How likely are you to continue purchasing and using the Disposable LACLS for infection control in your setting?
8. How likely are you to continue purchasing and using the Disposable LACLS for all clients in your setting whether or not infection control is necessary?
9. How likely are you to recommend the Disposable LACLS to colleagues?
10. Please share any other comments about the Disposable LACLS for use in infection control.
Your answer
Customer Profile
Please complete the following customer profile items 11-21 as directed. These items are for data analysis purposes only. We will make certain that your responses are kept anonymous and that survey results do not contain information that might personally identify you.
11. What is your profession? (Select all that apply)
Required
12. What is the city where your facility is located?
Your answer
13. What is the state where your facility is located?
Your answer
14. What is the country where your facility if located?
Your answer
15. What is the type of facility where you work? (Select all that apply)
Required
16. What is the age range of the clients in your facility who might require that infection control procedures be followed? (Select all that apply)
Required
17. What is your primary role in your facility?
18. How many times have you administered and scored the Disposable LACLS using the Manual for the ACLS-5 and LACLS-5 (2007)?
Optional Profile Information
If you chose to provide your name and email address, this identifying information will not be associated with your responses to items 1-18 above.
19. What is your name? (optional)
Your answer
20. What is your email address? (optional)
Your answer
21. Are you interested in participating in a study of the psychometric properties of the Allen Cognitive Level Screen-5, the Large Allen Cognitive Level Screen-5, and the Disposable Large Allen Cognitive Level Screen-5? If "yes," please complete items 19 (name) and 20 (email) so that we may contact you.
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