Form #3 Form #3 Web-based seminar evaluations

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

WEBINAR 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 Webinar: __________________________ Date: _______________________

Information about you and your agency:

Type of agency:

 Medicaid

 SCHIP

 Combined Medicaid / SCHIP

Please list your role in your agency: ___________________________

Basic	Intermediate	Advanced
		

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

Your evaluation of the webinar:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The webinar was clearly presented.     

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

The presenter was knowledgeable.     

The presenter answered my questions.     

The webinar was well organized.     

I would consider attending another

webinar in the future.     

Public reporting burden for this collection of information is estimated to average 25 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

Too slow	About right	Too fast
		

Please rate the pace of the webinar:

Too short	About right	Too long
		

Please rate the length of the webinar:

Too basic	About right	Too advanced
		

Please rate the level at which the webinar

was presented:

Not enough Interaction	About right	Too much Interaction
		

Please rate the level of interaction in

this webinar:

What topics in this webinar were most helpful?

What topics in this webinar were least helpful?

Were there any topics not discussed in this webinar that you wish were discussed?

Please provide any additional comments below: