Form 0920-0995 Att 15 Practicum Long-Term Evaluation wordversion

National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC): Evaluation

OMB No. 0920-0995

Attachments 15 & 16

Practicum Long-Term Evaluation Instrument

Word version and screenshot

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M M D D Y Y

TODAY’S DATE

Your confidential ID number is the first two letters of your FIRST name, the first two letters of your LAST name, the MONTH of your birth, and the DAY of your birth. For example: John Smith, May 29 would be JOSM0529

FN	FN	LN	LN	M	M	D	D

CONFIDENTIAL IDENTIFIER

Practicum Long-Term Evaluation

Public reporting burden of this collection of information is estimated to average 3minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0995).

A1f. I am using what I learned in this training in my work.

strongly disagree











Strongly agree

77

NA

A2f If you have not used what you learned, please explain why not.

A3f Did you make a change in your practice or worksite setting as a result of this training?

 Yes

 No

 Not applicable to my job or patients

 I was already using these practices

 Other reason (please specify)

A4f If you made a change, what change did you make?

A5f As a result of this training, did you share what you learned with any of the following? (select all that apply)

 Supervisor

 Colleagues/co-workers

 Policy makers

 Community

 Other (please specify) _____________________________

A6f Did any of these factors MAKE IT HARDER for you to apply the STD practices recommended in the training?

(select all that apply)

 lack of time with patients

 more important patient concerns

 cost/lack of reimbursement

 policies where I work

 resistance to change by supervisor or colleagues

 lack of equipment or supplies

 no opportunity to apply practices

 nothing interfered

 other, please specify ___________________________________________________

A7f Did any of these factors HELP you incorporate the STD practices recommended in the training?

(select all that apply)

 reimbursement or other financial incentive

 support of supervisor and/or colleagues

 standing orders

 reminder in chart

 convenient supplies

 posted patient instructions for obtaining specimens

 nothing specific helped

 other, please specify ___________________________________________________

UseGuidef Do you use the CDC STD Treatment Guidelines to guide the care of your patients/clients?

No, I am not aware of the Guidelines

I am aware of the Guidelines but do not use them

I use the Guidelines occasionally

I use the Guidelines consistently

I use another source to guide my STD care (please specify) ______________