Form 1 Health Literacy Training for Health Professionals Custom

OMB Number 0915-0212

Expiration date 7/31/2015

Health Literacy Project Health Professionals Satisfaction Survey

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 0.08 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 10C-03I, Rockville, Maryland, 20857.

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MM DD YY

TODAY’S DATE

Your unique ID number is the first two letters of your first name, the first two letters of your last name, the month of your birth, and the day of your birth. For example: John Smith, May 29 would be JOSM0529

UNIQUE IDENTIFIER

   

FN FN LN LN M M D D

Demographic Information

1. What is your racial background? (Select all that apply)

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Pacific Islander

 White

2. Are you of Hispanic, Latino/a, or Spanish origin?

 Yes  No

Training Design and Delivery

Circle one response for each question.

3. Please rate your overall satisfaction with the course.

Highly Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Highly Satisfied
1	2	3	4	5

Not at all Helpful	Somewhat Helpful	Helpful	Very Helpful
1	2	3	4
1	2	3	4
1	2	3	4
1	2	3	4

Please rate how helpful the following aspects of the training were in your learning about health literacy.

3. Organization of course

4. Course manual and handouts

5. Course activities and exercises

6. Course presentation slides and lectures

Please rate this training in the following areas.

3. Course length

4. Course level

5. Too Long	Long	Just Right	Short	Too Short
   1	2	3	4	5
   Too Basic	Basic	Just Right	Complex	Too Complex
   1	2	3	4	5
   Too Slow	Slow	Just Right	Fast	Too Fast
   1	2	3	4	5

   Course pace

Trainer Skills

3. Trainers were knowledgeable about the subject matter.

4. Trainers conducted training in an organized manner.

5. Trainers communicated information clearly.

6. Trainers facilitated the course effectively.

7. Trainers were responsive to questions.

8. Trainers worked well together.

9. Comments for Individual Trainers:___________

__________________________________________

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	2	3	4	5
1	2	3	4	5
1	2	3	4	5
1	2	3	4	5
1	2	3	4	5
1	2	3	4	5

Other Suggestions

3. How could this course be improved? ____________________________________________________________________________________________________________________________________________________________________