Surgical Quality Assurance Evaluation

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1. Contact and Order Information

Contact and Order Information   Company/Institution
Harlan order number or PO number
Date shipment received
Contact name
Contact title/position
Contact phone
Contact email

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2. Please check your response:

	1-Poor	2	3	4	5-Excellent
Overall condition of this shipment	*Please check your response: Overall condition of this shipment 1-Poor	Overall condition of this shipment 2	Overall condition of this shipment 3	Overall condition of this shipment 4	Overall condition of this shipment 5-Excellent

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3. Please provide order details below, with animal IDs and date of observation:

Please provide order details below, with animal IDs and date of observation:   Patency (CP=completely patent, PP=partially patent/infusion only, NP=non patent)
Incision/Excision Appearance
Body Condition (include animal weights if concerned)
Overall Appearance (hair coat, hydration, porphyrin staining, lesions, mobility and posture)
Other

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4. Please check your preference:

	1-Unacceptable	2	3	4	5-Exceeded Expectations
Overall satisfaction with this order	*Please check your preference: Overall satisfaction with this order 1-Unacceptable	Overall satisfaction with this order 2	Overall satisfaction with this order 3	Overall satisfaction with this order 4	Overall satisfaction with this order 5-Exceeded Expectations

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5. Were you able to complete your study with the number of animals provided?

Were you able to complete your study with the number of animals provided?   yes no

6. What did you like about this order?

What did you like about this order?

7. How can we improve your future order?

How can we improve your future order?

8. What other surgical services would you like Harlan Laboratories, Inc. to be able to provide?

What other surgical services would you like Harlan Laboratories, Inc. to be able to provide?

9. Would you recommend Harlan surgical services?

Would you recommend Harlan surgical services?   yes no

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10. Would you like a Harlan technical representative to contact you?

Would you like a Harlan technical representative to contact you?   yes no

11. Please include additional comments and concerns here:

Please include additional comments and concerns here: