Form #2 Form #2 Workshop evaluations

Technical Assistance for Health IT and Health Information Exchange in Medicaid and SCHIP

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

WORKSHOP EVALUATION FORM

Thank you for taking time to complete this form. Your feedback is important in helping us provide the most valuable assistance to Medicaid and SCHIP agencies.

Title of Workshop: __________________________ Date: _______________________

Information about you and your agency

Type of agency:

 Medicaid

 SCHIP

 Combined Medicaid / SCHIP

Please list your role in your agency: ___________________________

Please rate your agency’s status with regard to Health IT implementation.

Basic	Intermediate	Advanced
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Your evaluation of the workshop

How would you rate the overall quality of the workshop?

Very Poor	Poor	Neutral	Good	Very Good
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How would you rate the overall usefulness of the workshop?

Not at all useful	Not very useful	Neutral	Somewhat Useful	Very useful
				

Public reporting burden for this collection of information is estimated to average 50 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850

What was your favorite part of the workshop?

What was your least favorite part of the workshop?

Please rate how much you agree with the following statements:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The workshop was clearly presented.     

The content was relevant to my work.     

The presenter was knowledgeable.     

The presenter answered my questions.     

The workshop was well organized.     

Too slow	About right	Too fast
		

Please rate the pace of the workshop:

Too short	About right	Too long
		

Please rate the length of the workshop:

Too basic	About right	Too advanced
		

Please rate the level of the workshop:

Are there any additional topics you would like to have covered?

Please provide any other comments below: