Form A Form A For Participants in the Bullying Prevention Modul

Form A: Feedback Form for Bullying Prevention Training Module Participants
(Completed Immediately After the Training)

Thank you for your participation in the Bullying Prevention Training. This form will be used to assess the Training Module and Community Action Toolkit resources. Your feedback on the content and quality of the Training Module and Community Action Toolkit is appreciated.

Participant Information

Please provide your name and email address for follow-up in 4 months.

Trainee Name: (optional) Email: (optional)

Name/Address of Organization (optional): ____________________________________

1. What profession/sector do you represent? (if applicable):

 Education

 Government & Elected Officials

 Health & Safety

 Law Enforcement

 Child Care/After School & Out-of-School Care

 Faith-Based

 Corporation or business

 Mental Health & Social Service

 Parents & Caregivers

 Youth Leaders Organizations
 City/County Recreation

 Other (explain) ______________________

2. Date/Location of Training: _______________________________________

Training Satisfaction

3. Please rate how satisfied you are overall with the Training Module and Community Action Toolkit.

	Not Satisfied	Neutral	Satisfied
Bullying Defined	1	2	3
Description of the Many Forms of Bullying	1	2	3
Ten Key Findings About Bullying	1	2	3
Best Practices in Bullying Prevention & Response	1	2	3
Misdirections in Bullying Prevention & Response (video)	1	2	3
Case Studies: What’s Working in Bullying Prevention & Response	1	2	3
Action Planning & Group Brainstorm	1	2	3
Next Steps: Putting What You Learned Into Practice	1	2	3
Community Action Toolkit	1	2	3

4. Before this training, how knowledgeable were you about the issue of bullying and best practices in bullying prevention and response?

 Extremely knowledgeable about best practices

 Very knowledgeable about best practices

 Somewhat knowledgeable about best practices

 Limited knowledge about best practices

5. After this training, how knowledgeable are you overall about the issue of bullying and best practices in bullying prevention and response?

 Extremely knowledgeable about bullying and best practices

• Very knowledgeable about bullying and best practices

 Somewhat knowledgeable about bullying and best practices

 Limited knowledge about bullying and best practices

6. What did you like the most about the Training Module and Community Action Toolkit?

6. What changes or additions would most improve the Training Module and Community Action Toolkit?

6. How likely would you be to use the Training Module and Community Action Toolkit to:

	Not likely at all	Somewhat likely	Very Likely
Acquaint colleagues/staff about bullying	1	2	3
Conduct bullying awareness workshop at regional or national conferences	1	2	3
Hold a bullying awareness workshop for a local chapter/association/meeting of colleagues (single sector)	1	2	3
Organize a multi-agency/discipline group to convene a town hall or community event to raise awareness	1	2	3
Organize a multi-agency/discipline group to convene a community event and facilitate action plans for prevention responses	1	2	3
Other (please specify): ________________________________

6. Do you plan to hold a community event on bullying when you return to your community?

 Yes

 No

 Not Sure

6. What additional information or support do you need to be able to assume the roles and carry out tasks you have indicated an interest in doing?

Thank you for taking the time to provide feedback!

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

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Approved OMB # 0915-0212 Exp. Date 07/31/2015