Form Approved
OMB No.0990-0379
Exp. Date 08/31/2017
Region X Office of the Assistant Secretary for Health
Thank you for participating in our webinar or meeting. Please take a moment to complete this brief, anonymous survey. Your comments will help us improve our educational outreach efforts.
REQUIRED QUESTIONS
How would you rate the following statements?
The webinar/meeting increased my knowledge and understanding about [insert topic].
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
I intend to apply what I learned in my work.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
The webinar/meeting was applicable and relevant.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
I am satisfied with the overall quality of the webinar/meeting.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
Please share suggestions for other topics or for improving future webinars/meetings.
OPTIONAL QUESTIONS
My understanding of the role of my agency/division/department in addressing the [insert topic] has increased.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
My understanding of prioritizing the needs of various populations [insert topic] has increased.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
I am able to identify at least one new promising practice relevant to addressing [insert topic] in our community.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
I am able to identify at least one new resource that can help inform efforts to address [insert topic] in our community.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
I am able to identify next steps to advance efforts to [insert topic] in our community.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed to complete and to review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
I plan to follow-up and explore potential partnerships/collaborations with others that I met today.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
The [Name of Webinar or Meeting] has increased my practical skills regarding [Topic 1]. (Insert/delete as many topics as necessary)
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
As a result of the [information I learned, knowledge I gained] through the [Name of Webinar or Meeting], I will be more effective in my work.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
As a result of my involvement in the [Name of Webinar or Meeting], I have improved my connections with peers/colleagues.
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
As a result of my participation, I am able to [Name of Webinar or Meeting – Goal 1]. (Insert/delete as many objectives/goals as necessary)
☐ Strongly Agree ☐ Agree ☐ Neutral ☐ Disagree ☐ Strongly Disagree
Which of the following best describes your position? (Check all that apply)
State or local public agency leadership (Commissioners, Directors, Deputies)
Program Managers/ Program Director
Supervisors
Case Workers/Direct Practice Workers
Researcher
Policy Maker
Technical Assistance/ Consultant
Advocacy
Other (Please describe)
Which of the following best describes your organizational affiliation? (Check all that apply)
State public agency
Local or county public agency/organization
Federal agency
Legislature
Non-profit (e.g. community-based organization, faith-based organization)
Territory
Tribal agency/organization
Training and technical assistance provider
Philanthropy or foundation
Early, Elementary, and Secondary Education
Higher Education
Other (Please describe)
OPTIONAL OPEN-ENDED QUESTIONS
What aspects of the [Name of Webinar or Meeting] were most useful for your work?
Do you have any other comments or suggestions for the planning group?
| File Type | application/msword |
| File Title | Form Approved |
| Author | DHHS |
| Last Modified By | Windows User |
| File Modified | 2017-05-04 |
| File Created | 2017-05-04 |