SA/LA - User Response, Feedback, and Request Forms

Attachment 10

Eat Smart, Live Strong User Response Form

ACTIVITY KIT USER RESPONSE FORM

We want hear from you! Complete this form and press the submit button to share your feedback. We will use your thoughts and ideas to improve or modify the materials when possible.

1. Who are you? (Check all that apply.)

 Cooperative Extension Agent	 Food Stamp Nutrition Educator	 Farmers’ Market Provider
 Commodities Program Provider	 Food Bank Provider	 Senior Activities Coordinator
 Faith Based Provider	 Healthcare Provider	 Other _____________________

2. What do you think of the Activity Kit? (Check and rate all the items or activities you used.)

Very Useful Not Useful

 Leader’s Guide 5 4 3 2 1

 Eat Smart, Live Strong Flyer 5 4 3 2 1

 Session 1 Skill Building Activities 5 4 3 2 1

 Session 1 Exercises 5 4 3 2 1

 Session 1 Handouts 5 4 3 2 1

 Session 2 Skill Building Activities 5 4 3 2 1

 Session 2 Exercises 5 4 3 2 1

 Session 2 Handouts 5 4 3 2 1

 Session 3 Skill Building Activities 5 4 3 2 1

 Session 3 Exercises 5 4 3 2 1

 Session 3 Handouts 5 4 3 2 1

 Session 4 Skill Building Activities 5 4 3 2 1

 Session 4 Exercises 5 4 3 2 1

 Session 4 Handouts 5 4 3 2 1

3. Tell us how the materials were useful to you.

4. Tell us how the materials were not useful to you.

5. Other Comments:

2