Drug-O-Gram Feedback Form

Using a scale of 1 to 5 (with 1 being not useful at all and 5 being very useful), please rate how useful you find this program?

1	2	3	4	5
Not Useful				Very Useful

Please describe how the drug-o-gram was used? (Click all that apply)

	To determine a patient’s treatment regimen prior to availability of culture results
	To determine a patient’s treatment regimen after culture results became availability
	To monitor a patient’s response to treatment
	For use in a case presentation or paper
	To obtain medical consultation from another physician
	Other, please specify:

Did you experience any of the following difficulties while using this program? (Click all that apply)

	Installing/downloading the program
	Using menu options
	Using pull down menus
	Saving/opening a drug-o-gram
	Deleting drugs, smear, culture, susceptibility/DOT adherence
	Using the zoom range feature
	Inserting the drug-o-gram into a Powerpoint presentation
	Other, please specify:

What did you find most useful?

What did you find least useful?

What would you suggest to improve the Drug-O-Gram?

Please provide your e-mail address below if we may contact you for additional information.