Form 2 CE Evaluation Follow-up Form

Form 2: CE Evaluation Follow-up Form

Participants’ Evaluation Responses from the email/phone follow-up evaluation

¹¹1. At the CE offering, I made a commitment to improve something. Yes____# No ____#
If ‘Yes’ please identify the area/activity you committed to change. ____________________________
As relates to the change you identified have you:

Begun to implement? ____# Planning to implement? _____# Decided not to implement? ____#

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

Begun to implement? ____ # Planning to implement? _____# Decided not to implement? ____#

¹³ 3. If I have begun to implement asking my patients/clients if they or any close family members have served or are serving in the military, I do so:

Always           Usually               About half the time     Seldom        Never 

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

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

Begun to implement? ____# Planning to implement? _____# Decided not to implement? ____#

¹⁵5. 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?

Begun to implement? ____ Planning to implement? _____ Decided not to implement? ____

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

Begun to implement? ____ Planning to implement? _____ Decided not to implement? ____

¹⁷For Licensed Primary Care and Behavioral Health Professionals ONLY

7. 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? _____ Already enrolled? ____

¹⁸For Licensed Primary Care and Behavioral Health Professionals ONLY

8. I am a TriCare (Military Health Care Insurance) Provider.

Yes? ____ No? _____ Already enrolled? ____

Participants’ Evaluation Responses from the email/phone follow-up evaluation
111. At the CE offering, I made a commitment to improve something. Yes, No If ‘Yes’ please identify the area/activity you committed to change. As relates to the change you identified have you: Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Change in professional’s behavior		CE-1a.2 Col 3 VMH Project data
12 2. I will ask my patients/clients if they or any close family members have served or are serving in the military. Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Change in professional’s behavior		CE-1a.2 Col 3 VMH Project data
133. If I have begun to implement asking my patients/clients if they or any close family members have served or are serving in the military. Always, Usually, About half the time, Seldom, Never	Project OUTCOMES: Change in professional’s behavior rate		VMH Project data
144. I will assess veteran/service member patients or clients for signs and symptoms of Traumatic Brain Injury. Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Change in professional’s behavior		CE-1a.2 Col 3 VMH Project data
155. 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? Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Change in professional’s behavior		CE-1a.2 Col 3 VMH Project data
166. I will refer patients/clients to the PTSD resource: http://www.ptsd.va.gov Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Change in professional’s behavior		CE-1a.2 Col 3 VMH Project data
17For Licensed Primary Care and Behavioral Health Professionals ONLY 7. 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). Begun to implement, Planning to implement, Decided not to implement.	Project OUTCOMES: Access to care. Provide the number for each response item.		CE-1a.2 Col 3 VMH Project data
18For Licensed Primary Care and Behavioral Health Professionals ONLY 8. I am a TriCare (Military Health Care Insurance) Provider. Begun to implement, Planning to implement, Decided not to implement.	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