Form 1496 Course Evaluation Form

Completion time: 5 minutes OMB Control Number: 2127-NEW
Expiration Date: XX/XX/XXXX

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is 2127-NEW (expiration date: MM/DD/YYYY). The average amount of time to complete the survey is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Education Course Evaluation Form (H)

We are constantly trying to improve the quality of the course you just completed. Your inputs are greatly appreciated and will help make the course better.

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Circle one number on each line below that best describes how much you agree or disagree with each statement. Circling 1 means that you Strongly Disagree with the statement, and circling 5 means that you Strongly Agree with the statement. The numbers 2, 3, and 4 indicate a level in-between.

Strongly Strongly

Disagree Agree

The course presentation was well-organized and to the point	1	2	3	4	5
The instructor knew the material well	1	2	3	4	5
I understood the [instructor, presentation] well	1	2	3	4	5
For me, this [instructor, presentation] was effective	1	2	3	4	5
It was easy to participate and ask questions	1	2	3	4	5
I learned something new from this course	1	2	3	4	5
It would be hard for someone to ignore the course message	1	2	3	4	5
I will discuss what I learned with friends and family	1	2	3	4	5
I am glad that I took the course	1	2	3	4	5

Comments or suggestions:

NHTSA Form 1496