Form 1 Form A Bullying Prevention Online Program - 06232015

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 to receive a short follow-up survey in approximately 4 months.

Trainee Name: (optional) Email: (optional)

Name/Address of Organization (optional): ____________________________________

Feedback: Bullying Prevention & Response Training and Continuing Education Online Program

1. What profession/sector do you represent?

   1. Education

   2. Health & Safety

   3. Law Enforcement

   4. Child Care/After-School & Out-of-School Care

   5. Faith-Based

   6. Corporation or business

   7. Mental Health & Social Service

   8. Parents & Caregivers

   9. Youth Leaders Organizations

   10. City/County Recreation

   11. Government & Elected Officials

   12. Other, please specify:__________________

2. Please rate how satisfied you are overall with the bullying prevention continuing education online course.

   1. Very Satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very Dissatisfied

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

   1. Very knowledgeable

   2. Knowledgeable

   3. Somewhat knowledgeable

   4. Not at all knowledgeable

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

   1. Very knowledgeable

   2. Knowledgeable

   3. Somewhat knowledgeable

   4. Not at all knowledgeable

5. After completing the training, how likely are you to do the following (please select one response per row):

Activity	Very Likely	Likely	Unlikely	Very Unlikely
Acquaint colleagues/staff about bullying				
Conduct bullying awareness workshop at regional or national conferences				
Hold a bullying awareness workshop for a local chapter/association/meeting of colleagues (single sector)				
Organize a multi-agency/discipline group to convene a town hall or community event to raise awareness				
Organize a multi-agency/discipline group to convene a community event and facilitate action plans for prevention responses				

6. What did you like most about the training?

7. What aspects of the training could be improved?

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 .16 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.