Form 1 PCFDI

OMB No. 0915-0212

Expiration Date: 7/31/2015

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 1/6 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.

Post Program Survey

OMB No. 0915-0212

Expiration Date: 7/31/2015

Participant ID:

For each of the items below please use the scale to rate the quality of the meeting planning and logistics.

MEETING LOGISTICS	Poor	Adequate	Good	Excellent	Outstanding
Pre-meeting communication	1	2	3	4	5
Hotel accommodations	1	2	3	4	5
Meeting space	1	2	3	4	5
Ease of travel	1	2	3	4	5
Overall logistics	1	2	3	4	5

For each of the sessions you took part in, please use the scale below to rate the quality of the presentation.

PRESENTATION QUALITY	Poor	Adequate	Good	Excellent	Outstanding
Leadership Skills
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5
Change Management Skills
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5
Teamwork Skills
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5
Population Management
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5
Competency Assessment
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5
Clinical Microsystems
Presenter Skills	1	2	3	4	5
Topic Materials	1	2	3	4	5

For each of the sessions you took part in, please use the scale below to rate the usefulness of the information presented.

USEFULNESS	Not at all Useful	SomewhatUseful	Moderately Useful	Very Useful	Exceptionally Useful
Leadership Skills	1	2	3	4	5
Change Management Skills	1	2	3	4	5
Teamwork Skills	1	2	3	4	5
Population Management	1	2	3	4	5
Competency Assessment	1	2	3	4	5
Clinical Microsystems	1	2	3	4	5

For each of the sessions you took part in, please use the scale below to rate your intention to implement what you learned when you return to your institution.

INTENTION TO IMPLEMENT	Unlikely to Implement	Somewhat Likely to Implement	Moderately Likely to Implement	Very Likely to Implement	Absolutely Will Implement
Leadership Skills	1	2	3	4	5
Change Management Skills	1	2	3	4	5
Teamwork Skills	1	2	3	4	5
Population Management	1	2	3	4	5
Competency Assessment	1	2	3	4	5
Clinical Microsystems	1	2	3	4	5