Regional Extenion Center

Form Approved

OMB No. 0955-0009

Exp. Date 05/16/2017

Workforce Training Program Evaluation

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 0955-0009. The time required to complete this information collection is estimated to average ( hours)(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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Workforce Training Program Evaluation Form

The Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology is distributing this survey to collect information about its Workforce Training Program. Your participation is greatly appreciated. Your answers are completely confidential. If you have any questions about this survey please contact xxxxxx.

Tell us about the training you took.
Which educational institution sponsored the training you participated in?	[WILL BE PRE-POPULATED WITH ALL EDUCATIONAL INSTITUTIONS IN THE GIVEN CONSORTIUM.]
What is the title of the training you took?	Training Title: a. __________________ b. Do not know
When did you take this training?	1. Training Date: a. __________________ b. Do not know
4) How was the training delivered (i.e., format)? [CHECK ALL THAT APPLY.]	In-person Webinar Self-paced on-line training Instructor-led online training Video conference Virtual discussion forums Other __________________
5) Did you complete the training	1. Yes (skip to question 7) 2. No (go to question 6)
6) Why didn’t you complete the training?	1. I was too busy to complete training. 2. Training was not offered during a time when I was available. 3. There were too many modules for me to complete. 4. I only completed the modules that were relevant to my current work. 5. Other _____________ [SKIP TO QUESTION 16]
Please read the following statements and indicate the extent to which you agree or disagree with each. I feel that this training….
7) Met its objectives.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
8) Helped me understand the subject matter.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
9) Had training materials (e.g., readings, slide decks, lectures) that were helpful.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
10) Covered content that was relevant to the healthcare and health IT industry.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
11) Covered content that was relevant to my job.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
12) Kept me actively engaged during the training.	Strongly Agree Somewhat Agree Neither Agree Nor Disagree Somewhat Disagree Strongly Disagree
13) Had a presenter that effectively demonstrated proficiency in the subject matter.	Strongly Agree Somewhat Agree Neither Agree Nor Disagree Somewhat Disagree Strongly Disagree NA-No Instructor
Please answer the following additional questions.
14) The skills I learned in the training will improve my job performance.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
15) I would recommend this course to others.	1. Strongly Agree 2. Somewhat Agree 3. Neither Agree nor Disagree 4. Somewhat Disagree 5. Strongly Disagree
16) What other training topics would you be interested in learning about?	Open-ended
17) How, if at all, would you recommend that this course be changed to make it more useful to other participants?	Open-ended
Tell us about yourself.
18) Sex	Female Male
19) Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
20) Ethnicity	(Hispanic/Latino) Non-Hispanic/Latino
21) Age	1. 18-24 2. 25-34 3. 35-44 4. 45-54 5. 55-64 6. 65-74 7. 75+
22) Education Level	High school graduate Some college credit, no degree Trade/technical/vocational training Associate degree Bachelor’s degree Master’s degree/ Professional degree (e.g. MD, DDS, DVM, LLB, JD) Doctorate degree (e.g. PhD, EdD)
23) Job Position	Physician(s) Mid-level Provider Nurses (RNs and LVNs) Practice Manager Medical Assistants Billing Personnel Medical Clerk Other: ______________________
24) What type of facility do you work in?	ACO Federally Funded Clinic Federally Funded Hospital Hospital Practice Other:_________________________

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