2 Form B Follow-Up Form For Participants in the Bullying P

Form B: Evaluation Form for Bullying Prevention Training Module Participants

(Completed Four Months After the Training Module)

Thank you for your participation in the HRSA Bullying Prevention Training on . This form will be used to gain an understanding of how helpful the Training Module and Community Action Toolkit was in meeting your bullying prevention and response goals.

1. Since completing the training, have you conducted activities using the Bully Prevention Training Module and/or Community Action Toolkit?

   1. Yes (continue to question 2)

   2. No (end survey)

2. Since completing the training, have you shared the Bullying Prevention Training Module?

___Yes (skip to questions 2a and 2b)

___No (skip to question 3)

1. If yes, how have you shared the Module? (Please select all that apply)

1. Shared presentation by email

2. Provided copies of the presentation to others

3. Presented the Training Module

4. Other, please specify: __________

2. With what professions or groups have you shared the Module? (Please select all that apply)

1. General public/community members

2. Education

3. Health & Safety

4. Law Enforcement

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

6. Faith-Based

7. Corporation or business

8. Mental Health & Social Service

9. Parents & Caregivers

10. Youth Leaders Organizations

11. City/County Recreation

12. Government & Elected Officials

13. Other, please specify:______________

3. Since completing the training, have you shared the Community Action Toolkit?

___ Yes (skip to questions 3a and 3b)

___ No (skip to question 4)

1. If yes, how have you shared the Community Action Toolkit? (Please select all that apply)

1. Shared Community Action Toolkit by email

2. Provided copies of the Community Action Toolkit to others

3. Used the Community Action Toolkit to host an event

4. Other, please specify:_____________

2. With what professions or groups have you shared the Community Action Toolkit? (Please select all that apply)

1. General public/community members

2. Education

3. Health & Safety

4. Law Enforcement

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

6. Faith-Based

7. Corporation or business

8. Mental Health & Social Service

9. Parents & Caregivers

10. Youth Leaders Organizations

11. City/County Recreation

12. Government & Elected Officials

13. Other, please specify:______________

4. Since completing the training, have you conducted any community events using information or resources from the Bullying Prevention Training Module and/or Community Action Toolkit?

___ Yes (skip to question 4a)

___ No (skip to question 5)

1. If yes, how many community events have taken place since you participated in the Bullying Prevention Training Module? ____

5. What other information, materials, or resources would be helpful as you conduct activities using the Bullying Prevention Training Module and/or Community Action Toolkit?

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 .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 10-29, Rockville, Maryland, 20857.

3