Workshop Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

Chronic Disease Self-Management Workshop Evaluation

Public reporting burden of this collection of information is estimated to average 10 minutes per response for the submission of Evaluation Data, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-XXXX)

Please help us evaluate the workshop by filling out this form.

1. I took this course because (please check all boxes that apply)

☐ I have a chronic condition

☐ I take care of someone with a chronic condition

☐ I want to learn about self-management

☐ Another reason: __________________________________

2. How did you hear about the workshop?

☐ Doctor or health care provider ☐ Brochure ☐ Flier ☐ Newspaper

☐ Television ☐ Radio ☐ Other_______________________________

Please rate the workshop classes by circling one number for each question below

3. Sign-up process ……………………………….. Poor 1 2 3 4 5 Excellent

4. Time/day classes were held……………… Poor 1 2 3 4 5 Excellent

5. Place where classes were held….……… Poor 1 2 3 4 5 Excellent

6. Satisfaction with workshop leaders….. Poor 1 2 3 4 5 Excellent

7. What did you like best about the workshop?

8. What did you like least about the workshop?

9. Do you have any suggestions on how the workshop may be improved?

10. How likely are you to use what you learned from the workshop in your own life?

Not likely at all 1 2 3 4 5 6 7 8 9 10 I will definitely use what I learned

11. How likely are you to share what you learned with your doctor or health care provider?

Not likely at all 1 2 3 4 5 6 7 8 9 10 I will definitely share what I learned

For each of these questions, please circle the number that describes the confidence you have to complete each task at this time:

12. Revise an action plan that you made to deal with problems and challenges

Not confident 1 2 3 4 5 6 7 8 9 10 Very confident

13. Manage your symptoms or health problems so you can do what you need to do

Not confident 1 2 3 4 5 6 7 8 9 10 Very confident

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