Form 1 ORO Generic Evaluation Survey January 2017 - FINAL DRAFT

Participant Feedback Form

Title of Activity

(e.g., “webinar”/“presentation”/“technical assistance”/“grants workshop”)

to characterize the event when individualizing the survey

Date(s) of Activity

DIRECTIONS: Please take a few moments to complete this Feedback Form about your participation in this activity (e.g., webinar; presentations; technical assistance; grantee workshops) offered by HRSA’s Office of Regional Operations. Your feedback will help us improve future “activities” (e.g., webinar; presentations; technical assistance; grantee workshops). You will NOT be personally identified in any report of results. Please contact XX by phone XX, or by email XX if you have questions.

1. Please select the type of organization below that BEST describes your organization.

• Academic

• Community-Based

• Faith-Based

• Government

  • Federal

  • State

  • Local

• Health Center

• Rural Health

• Tribal

• Other (please specify): ____________________

2. Please select the category below that BEST describes your role in the organization.

• Community Advocate/Leader

• Educator

• Grant Writer

• Program Administrator/Coordinator

• Project Officer/Grants Management Specialist

• Program/Policy Analyst

• Provider/Clinician

• Other (please specify): ____________________

3. What motivated you to participate in this activity/event? Check All That Apply.

• Individual/Professional Development

• Continuing Education Requirement

• Unique Learning Opportunity

• Other: _____________________

4. How many people viewed the activity/webinar with you?

• None

• 1-5

• 6-9

• 10-15

• 16-20

• 21 or more

5. Please rate this activity for each of the following using a scale ranging from 1 = “Strongly Disagree” to 5 = “Strongly Agree.”

	Strongly Strongly Agree Disagree
Organization of the program was excellent.	5 4 3 2 1
Subject matter was relevant.	5 4 3 2 1
Content was clearly presented.	5 4 3 2 1
Amount of information presented was about right.	5 4 3 2 1
Pace of the program was suitable for learning.	5 4 3 2 1
Learned new knowledge and skills.	5 4 3 2 1
My expectations of this activity were met.	5 4 3 2 1
Presenters were informative, prepared, and understandable.	5 4 3 2 1
Materials (PowerPoint slides, handouts) used aided learning.	5 4 3 2 1
Presenters answered questions to my satisfaction.	5 4 3 2 1
Delivery method was appropriate.	5 4 3 2 1

6. Thinking about the activity/webinar I just attended, overall, I am…. (please circle one number):

1	2	3	4
Not at all Satisfied	A little Satisfied	Somewhat Satisfied	Very Satisfied

7. Using a scale ranging from 1 = “Extremely Unlikely” to 5 = “Extremely Likely,” please rate how likely you are to do each of the following because you participated in this activity/webinar:

	Extremely Extremely Likely Unlikely
Seek to learn more about HRSA funding and/or programs.	5 4 3 2 1
Apply for HRSA funding.	5 4 3 2 1
Inform others about HRSA.	5 4 3 2 1
Seek to form a new relationship/partnership.	5 4 3 2 1
Seek to implement a new service or best practice	5 4 3 2 1
Apply the knowledge and skills learned to my job.	5 4 3 2 1
Attend additional activities/webinars offered by HRSA.	5 4 3 2 1

8. Would you recommend this activity to others in your field?

• Yes

• No

9. What other topics would you like to see addressed in future activities/webinar offerings?

______________________________________________________________

10. Please provide up to two (2) suggestions to improve this activity if it is offered again in the future.

a. _____________

______ ______

______

b. ______

______

______

Thank you very much for your time and responses!