CBIT Program Evaluation

Tourette Syndrome Association CBIT Program Evaluation

“

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Comprehensive Behavioral Intervention for Tics”

Speaker, University

Date

Location

Learning Objectives:

1. Understand the impact of environmental events on tics

2. Summarize the current state of evidence regarding non-pharmacological interventions for tics

3. Describe the CBIT protocol for tic management

1. Please indicate your PROFESSION & SPECIALTY:

Physician___________ PA__________ Nurse _________ NP___________ Ph.D.___________ Psychologist__________

(specialty) (specialty) (specialty) (specialty) (specialty) (specialty)

Social Worker_________ Counselor _________ Occupational Therapist________ Other_____________

(specialty) (specialty) (specialty) (describe)

2. Do you have experience working with patients with TS or tic disorders? Yes____ No____

If yes, how many? 1-5 ___ 6-10 ___ more than 10 ___

3. Please rate your knowledge before and after participating in this program

Knowledge BEFORE program None Some A lot			Self-rating of your knowledge related to:	Knowledge AFTER program None Some A lot
1	2	3	Impact of environmental events on tics	1	2	3
1	2	3	Evidence for non-pharmacological interventions	1	2	3
1	2	3	CBIT protocol methods	1	2	3

4. How much of this content was new to you? Almost all____ 75%____ 50%____ 25%____ Almost none____

Please rate the following statements using a 1-4 scale, where 1 indicates strongly disagree and 4 indicates strongly agree

	Strongly disagree	Disagree	Agree	Strongly agree	N/A
5. My skills in diagnosing/recognizing TS will be improved as a result of this program	1	2	3	4
6. My skills in managing patients who have TS will be improved as a result of this program	1	2	3	4
7. If given an opportunity, I can apply the knowledge gained as a result of this program	1	2	3	4
8. I intend to educate patients with TS and their families about CBIT	1	2	3	4
9. I plan to refer TS patients to CBIT practitioners	1	2	3	4
10. I plan to implement CBIT with my patients with tics	1	2	3	4
11. The presenter communicated the content effectively	1	2	3	4

Please describe any changes to your skills, strategy and/or practice:

Suggestions to improve this program:

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