Form 1 CE Evaluation Results Form

Area Health Education Centers Project on the Mental and Behavioral Health and Substance Abuse Issues of Veterans/Service Members and Their Families

REVISED CE Evaluation Results Form

CE Evaluation Resuts Form

OMB: 0915-0352

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Participants’ Evaluation Responses at the end of the CE Offering

11. In this educational session I increased my knowledge of military culture.

Strongly Agree          Agree               Neither Agree nor Disagree   Disagree      Strongly Disagree Not Applicable/No response

            1____ #                     2____ #                     3____ #                    4____ #                    5 ____ # ____ #


22. In this educational session I increased my knowledge of veterans/service members and their families mental/behavioral health issues.

Strongly Agree          Agree              Neither Agree nor Disagree   Disagree      Strongly Disagree Not Applicable/No response

            1____ #                     2____ #                     3____ #                    4____ #                    5 ____ # ____ #


33. After completing this educational session I intend to improve __________________

____ # (participants who added any response)


44. I will ask my patients/clients if they or any close family members have served or are serving in the military.

Strongly Agree         Agree         Neither Agree nor Disagree    Disagree     Strongly Disagree  Not Applicable/No response

            1____ #              2____ #              3____ #                    4____ #                  5 ____ # ____ #


55. Before completing this educational session, I routinely asked my patients/clients if they or any close family members have served or were serving in the military.

Always           Usually               About half the time     Seldom        Never  Not Applicable/No response

            1____ #                     2____ #                     3____ #                    4____ #                    5 ____ # ____ #


66. I will assess veteran/service member patients or clients for signs and symptoms of Traumatic Brain Injury.

Strongly Agree         Agree         Neither Agree nor Disagree    Disagree     Strongly Disagree  Not Applicable/No response

            1____ #              2____ #              3____ #                    4____ #                  5 ____ # ____ #


77. When I am concerned about PTSD, I will ask: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you have had nightmares about it or thought about it when you did not want to?

Strongly Agree         Agree         Neither Agree nor Disagree    Disagree     Strongly Disagree  Not Applicable/No response

            1____ #              2____ #              3____ #                    4____ #                  5 ____ # ____ #


88.I will refer patients/clients to the PTSD resource: http://www.ptsd.va.gov

Strongly Agree          Agree         Neither Agree nor Disagree    Disagree      Strongly Disagree  Not Applicable/No response

            1____ #              2____ #              3____ #                    4____ #                  5 ____ # ____ #


9For Licensed Primary Care and Behavioral Health Professionals ONLY

9. I will enroll in the searchable online directory of health providers willing to serve the needs of service members that is maintained by the War Within database (http://warwithin.org/fhp.php).

Yes  ____ #  No ____ # I am already enrolled  ____ # 


10For Licensed Primary Care and Behavioral Health Professionals ONLY

10. I am a TRICARE (Military Health Care Insurance) Provider now. Yes  ____ #  No ____ # Not Applicable ____ #

I intend to become a TRICARE Provider. Yes  ____ #  No ____ # Not Applicable ____ #


FORM 1: CE Evaluation Results Form







Participants’ Evaluation Responses at the end of the CE Offering



11. In this educational session I increased my knowledge of military culture.

Strongly Agree, Agree, Somewhat Agree, Disagree, Strongly Disagree

  1. Project OUTCOMES: Change in knowledge

Provide the number for each response item.

CE-1a.2 Col 2

22. In this educational session I increased my knowledge of veterans/service members and their families mental/behavioral health issues.

Strongly Agree, Agree, Somewhat Agree, Disagree, Strongly Disagree

  1. Project OUTCOMES: Change in knowledge

Provide the number for each response item.


CE-1a.2 Col 2

33. After completing this educational session I intend to improve. _______
# participants who added any response






  1. Project OUTCOMES: Change in professional’s behavior
    report the # who give any response for this item.

CE-1a.2 Col 3 VMH Project data

44. I will ask my patients/clients if they or any close family members have served or are serving in the military.

  1. Project OUTCOMES: Change in professional’s behavior

Items 7 and 8 are designed as a ‘Retrospective Pretest ‘, also known as ‘Then Now’ questions. The protocol is to ask the participant to respond based on their answer after the educational offering and then reflect on how they would have responded before the educational offering. The sequencing of the questions is part of the design.

CE-1a.2 Col 3 VMH Project data

55. Before completing this educational session, I routinely asked my patients/clients if they or any close family members have served or were serving in the military.

  1. See above

CE-1a.2 Col 3 VMH Project data

66. I will assess veteran/service member patients or clients for signs and symptoms of Traumatic Brain Injury.

Strongly Agree, Agree, Somewhat Agree, Disagree, Strongly Disagree

  1. Project OUTCOMES: Change in knowledge

Provide the number for each response item.

CE-1a.2 Col 3

77. When I am concerned about PTSD, I will ask: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you have had nightmares about it or thought about it when you did not want to?

Strongly Agree, Agree, Somewhat Agree, Disagree, Strongly Disagree

  1. Project OUTCOMES: Change in professional’s behavior

Provide the number for each response item.

CE-1a.2 Col 3 VMH Project data


88.I will refer patients/clients to the PTSD resource: http://www.ptsd.va.gov

Strongly Agree, Agree, Somewhat Agree, Disagree, Strongly Disagree

  1. Project OUTCOMES: Change in professional’s behavior

CE-1a.2 Col 3 VMH Project data

9For Licensed Primary Care and Behavioral Health Professionals ONLY

9. I will enroll in the searchable online directory of health providers willing to serve the needs of service members that is maintained by the War Within database (http://warwithin.org/fhp.php).

  1. Project OUTCOMES: Access to care.
    Provide the number for each response item.

CE-1a.2 Col 3 VMH Project data

10For Licensed Primary Care and Behavioral Health Professionals ONLY

10. I am a TRICARE (Military Health Care Insurance) Provider now.

Yes, No, Not Applicable

I intend to become a TRICARE Provider.

Yes, No, Not Applicable

  1. Project OUTCOMES: Access to care.
    Provide the number for each response item.

CE-1a.2 Col 3 VMH Project data




2 A-TrACC VMH CE Report Form Guidelines

02/27/12

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