Form 0917-0036 IHS CHR Basic Online Training Evaluation

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Indian Health Service (IHS)

Community Health Representatives (CHR)

Basic Online Training Evaluation

1. What is your age?

1. 18-19

2. 20-29

3. 30-39

4. 40-49

5. 50-59

6. 60 and above

2. What is your sex?

1. Male

2. Female

3. What is the highest level of education you completed?

1. Middle School

2. Some high school

3. High school

4. Some college

5. College

6. Post graduate

4. Do you have any certifications? Yes ____ No _____. If yes, please select from list below.

1. CNA

2. LPN

3. EMT

4. RN

5. Other (specify) ________

5. How many years of experience do you have as a CHR? _______, Not Applicable ________

6. Is this the first time you are taking a CHR training course?Health Representative Health Represe

Yes _____ No ____

If no, when was the last time you took a CHR training (year) _________ and what was the mode of training

1. In-person through I/T/U

2. In-person through non I/T/U

3. Online through I/T/U

4. Online through non I/T/U

7. Do you think this CHR training was useful?

1. Yes

2. No

8. In the table below, assess your knowledge and skills before and after completing the CHR training modules. For each module, please select whether you had ‘no knowledge’, ‘some knowledge’ or ‘advanced knowledge’ for both ‘Before’ and ‘After’ CHR Training.

Modules	Before CHR Training			After CHR Training
	No or Little Knowledge	Some Knowledge	Advanced Knowledge	No or Little Knowledge	Some Knowledge	Advanced Knowledge
Introduction
Anatomy & Physiology
CHR Basic Skills
Infectious Control
Communicable Disease
Chronic Disease
Mental Health
Emergency Preparedness
Public Health
CNA Videos

9. In the below table, select whether you found each module useful or not useful.

Modules	Useful	Not Useful
Introduction
Anatomy & Physiology
CHR Basic Skills
Infectious Control
Communicable Disease
Chronic Disease
Mental Health
Emergency Preparedness
Public Health
CNA Videos

10. Do you feel more knowledgeable, capable and confident to utilize information acquired from this training in your work as a CHR?

1. Yes

2. No

11. Are you likely to change any behaviors/how you deliver services or apply knowledge gained from this training in your work as a CHR?

1. Not very likely

2. Somewhat likely

3. Very likely

4. Definitely

12. How likely are you to recommend this CHR training to someone?

1. Not very likely

2. Somewhat likely

3. Very likely

4. Definitely

Thank you for participating

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 0917-0036. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and 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 336E, Washington D.C. 20201. Attention: PRA Reports Clearance Officer.

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