NRC Online Module NRC Online Module Feedback Form

Attachment 2: NRC Online Learning Module Feedback Form

OMB No. 0930-0197

Expiration Date: 1/31/2017

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 0930-0197.  Public reporting burden for this collection of information is estimated to average 17 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Online Learning Modules (OLMs): The online feedback form for people who complete any of the Online Learning Modules (OLM). Immediately after completion of each OLM, the feedback form is provided to all participants should they be interested in providing feedback to the NRC. The feedback form is sent through and SurveyShare. The results are then analyzed and described in a summary report by NRC staff.

Module Feedback Form

[Insert title of Online Learning Module]

Thank you for completing the [insert title of online learning module] Online Learning Module (OLM). To continue to improve the quality of our OLMs, we ask that you please answer the following questions. Your participation is completely voluntary and confidential.

1. Are you a current or former Safe Schools/Healthy Students (SS/HS) or Project LAUNCH grantee?

□ Yes (select one)

□ SS/HS

□ Project LAUNCH

□ No

1a. If no, which of the following best describes your professional affiliation? (Check all the boxes that apply)

• Education (k-12) professional

• Special education professional

• Post-secondary/Higher education professional

• Early childhood (ages 0 – 5 years) professional

• Childcare professional

• Child welfare professional

• School health (nurse, clinic) professional

• Primary care (doctor, nurse, nurse practitioner)

• Mental health (psychologist, counselor, therapist, social worker) professional

• Juvenile justice/law enforcement professional

• Substance abuse (counselor, prevention) professional

• Government (federal, state, or local) employee

• National association member/staff

• Community-based/nonprofit organization professional

• Evaluator/researcher

• Family member/caregiver

• Other

1b. If other, please write your professional affiliation in the space below.

2. Please rate your knowledge of the topic [insert topic of online learning module] prior to completing this module.

□ Not knowledgeable

□ Slightly knowledgeable

□ Moderately knowledgeable

□ Very knowledgeable

3. Please rate your knowledge of the topic [insert topic of online learning module] after completing this module.

□ Not knowledgeable

□ Slightly knowledgeable

□ Moderately knowledgeable

□ Very knowledgeable

4. This module improved my understanding of [insert objective #1 of online learning module].

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. This module improved my understanding of [insert objective #2 of online learning module].

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. This module improved my understanding of [insert objective #3 of online learning module]

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. This module improved my ability to [insert objective #4 of online learning module].

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. The module delivered information in a clear manner and was easy to follow.

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. I plan to share information from this module with others.

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. I am motivated and will be able to apply information from this module in my work.

□ Strongly Disagree

□ Disagree

□ Agree

□ Strongly Agree

5. To what extent has this online learning module improved your knowledge of [for communication focused OLMs use: promoting mental health and/or prevention?] [for non-communication focused OLMs use: prevention/mental health promotion?].

□ Not at all

□ Slightly

□ Moderately

□ A great deal

5. Overall, how satisfied were you with this module?

□ Very dissatisfied

□ Somewhat dissatisfied

□ Somewhat satisfied

□ Very satisfied

5. Please provide at least one example of what you have learned from this module that you can apply to your work.

5. Please provide any additional comments about how to improve this online learning module and/or make suggestions for future topics that will help support your work:

Attachment 2 4